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Introduction to fractures and trauma. Principles of fractures. Fracture : it is break in the structural continuity of the bone . It is of two main types : 1- simple fracture ( closed ) . 2- compound fracture (open ) .i.e. associated with wound
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Principles of fractures Fracture : it is break in the structural continuity of the bone . It is of two main types : 1- simple fracture ( closed ) . 2- compound fracture (open ) .i.e. associated with wound connecting it to the external environment . How fracture happen : 1- single traumatic incident . 2- repetitive stress . 3- abnormal weakening of the bone ( pathological fracture ) .
In single traumatic incident the bone sustained sudden and excessive force which may be direct or indirect : In direct force the bone break at the point of impact ; while in indirect force the bone is break at distant from the site of force where it applied . The force which break the bone is of different types : A- twisting force . B- bending force . C-compression force . D- tension force . Each of them influence the shape of the fracture which is either spiral ,oblique , transverse , or fracture with butter – fly segment . all this is applied to the long bones . So the fractures either complete or incomplete : Complete could be transverse , oblique , spiral , or comminuted . And incomplete could be green stick orcompression fracture .
Fracture healing : immobilization of the fracture is not mandatory for fracture healing ; the splinting of the fracture to ensure : 1- pain relief . 2- union take place in good position . 3- early movement and return to function . Steps of fracture healing : 1- tissue destruction and haematoma formation . 2- acute inflammatory reaction and cellular proliferation . 3- callus formation (step of union) . 4- consolidation . 5- remodeling .
Time table : For fracture healing the time change according to age , blood supply , type of the fracture ……etc. Perkin`s time table is very simple table to asses that time : Spiral or oblique fracture in the upper limb unite in 3 weeks . Transverse fracture in the upper limbs unite in 6 weeks . For consolidation multiply by 2 . In the lower limbs : Oblique or spiral fracture need 6 weeks for union . Transverse fracture need 12 weeks . For consolidation multiply by 2 .
Clinical features of the fracture : A – symptoms : 1- history of trauma followed by inability to use the injured limb ; if the trauma is simple and weak force we suspect pathological fracture . 2- pain . 3- brusing . 4- swelling . 5- deformity . B – signs : 1- swelling . 2- Bruising . 3- deformity . 4- tenderness . 5- crepitus . 6- loss of function .
X – ray : it is mandatory for diagnosis of fractures . Role of twos : 1 – two views . 2 – two joints . 3 – two limbs . 4 – two injuries . e. g. fracture calcaneum . . 5 – two occasions e.g. fracture scaphoid 6 - two tissue . Special imaging: 1- tomography . 2- C.T. 3- MRI . 4- bone scan .
Treatment of closed fracture : A – the general treatment is the first consideration i. e. the air way patency , breathing and circulation . B – treatment of the fracture itself : this include : 1- reduction . 2- holding . 3- physiotherapy and rehabilitation . 1- reduction of the fracture : It should be taken in the first 12 hours from the trauma , because the oedema and swelling make the reduction difficult after that time . Two types of reduction : 1- closed reduction ( by manipulation ) . 2-open reduction ( by surgical approach ) .
Open reduction is indicated in : 1- when close reduction fail . 2- when there is large articular fragment need accurate reduction . 3- for traction fractures in which the fragments are held apart . Holding of the fractures : by : 1- continuous traction . 2- cast splintage ( plster of paris P.O.P) . 3- functional bracing . 4- internal fixation . 5- external fixation .
Traction : types of traction : 1- traction by gravity : this is used only in upper limb .e.g hanging cast . 2- skin traction : it is available in special kit , it is used mainly in the lower limb . 3- skeletal traction . Skin traction Principle of it's use : 1- applied distal to the fracture site . 2- weight used is 10% of the body wt. and not more than 5 kg , if we need more than 5 kg then we use skeletal traction . 3- removal of the hair before application . Indication of skin traction : 1- used in fractures of the lower limbs vertebras and pelvis . 2- in dislocations of the lower limbs . 3- for resting of the limb e.g. in arthritis , osteomyelitis , septic arthritis , irritable hip etc……. 4- in treatment of back ache .
Complication of skin traction : 1- allergy to the adhesive material of the plaster lead to ulceration of the skin . 2- compression of the vessels lead to compartment syndrome . 3- compression of the nerves lead to neuropraxia . 4- excessive traction (when use over wt.) lead to non union 5- failure of the kit . 3- skeletal traction : Pin is inserted distal to the fracture site usually behind the tibial tuberosity or lower femoral condyles , the wt. used is one six (1/6) of the body wt. . Complication : 1- broken of the pin . 2- pin tract infection . 3- over (excessive ) traction .
Methods of traction : A- fixed traction e.g. Thomas splint . B- balanced traction ( over pulleys ) . C- combined traction . D- counter traction . Cast splintage (p.o.p) : Plaster of Paris is calcium sulphate hemihydrates , it is very safe and easily used in holding of the fractures . Principles of using p.o.p : 1- in acute fractures , use the p.o.p in form of slabs to avoid compartments syndrome . 2- it should involve the joint below and the joint above of the fracture . 3- never applied directly on the skin (use cotton or any other material) . 4- it should never be done too tight or too loose , too heavy or too light .
