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Fracture & Dislocation

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    Fracture & Dislocation

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    fractures

    A fracture is a structural breech in the normal

    continuity of bone.

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    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

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    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).

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    Fracture healing

    Bone healing is usually divided into three

    slightly overlapping stages:

    1. inflammatory phase 2. reparative phase

    3. remodeling phase

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    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.

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    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.

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    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

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    Diagnosis

    Clinical:

    - History of trauma

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

    - Deformity, abnormal movement (sure signs offracture)

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    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

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    Principlesoffracture

    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.

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    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

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    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.

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    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

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    Methods of Immobilization

    1. External splints e.g plaster ofParis (POP)cast

    - Is the safest and cheapest method ofimmobilization

    - Immobilization should always include the twoadjacent joints

    - Joints should be immobilized in a functional

    position- Complications include joint stiffness and

    compartment syndrome.

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    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.

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    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

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    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.

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    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.

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    Complications of Fractures

    I. Soft tissue Injuries

    - Arteries,Nerves andViscera may be injured

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    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.

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    III. Infection

    -Usually complicates open fractures

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

    preventing infection.

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    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 ofa 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.

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    V. Joint complications

    Joint stiffness

    Secondary Hemarthrosis osteoarthritis

    VI.Systemic complications

    Usually follow polytrauma and major long bone

    fracture

    IncludeARDS and fat embolism syndrome

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    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.

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    Types 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.

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    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

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    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

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    Management

    Early reduction of the dislocation

    Immobilizing the joint to allow time for the

    supporting structures of the joint to heal Rehabilitation of the joint

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    AMPUTATIONS

    An amputation is removal or excision of part

    or whole of a limb.

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    Indications

    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.

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    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

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    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.

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    Complications of amputation

    Edema

    Hematoma

    Secondary and reactionary hemorrhage Infection

    Ischemic necrosis

    Flexion contracture Chronic pain-psychogenic, neuromas, etc.

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