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General Principles of Fracture Care. Presented By: Fadel Naim M.D. Orthopedic Surgeon Faculty of Medicine IUG. Fracture. The problem is not the damage to the bone The problem is the damage the bone does to the surrounding soft tissues. Evaluate Neurovascular Function Distally. Fracture.
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General Principles of Fracture Care Presented By: FadelNaim M.D. Orthopedic Surgeon Faculty of Medicine IUG
Fracture • The problem is not the damage to the bone • The problem is the damage the bone does to the surrounding soft tissues. • Evaluate Neurovascular Function Distally
Fracture • A disruption in the integrity of a living bone involving injury to: • Bone • Bone marrow • Periosteum • Adjacent soft tissues
Mechanisms of Musculoskeletal Injury • Direct force • Indirect force • Twisting (rotational) force
Direct trauma: • Consists of direct force applied to the bone • Tapping fractures (eg, bumper injury) • Penetrating fractures (eg, gunshot wound) • Crush fractures
Indirect trauma • Involves forces acting at a distance from the fracture site • Tension (traction) • Compressive forces • Rotational forces
Indirect Trauma Rotation Tension Compression Combination Angulation
ClassificationofFractures • Evidence based medicine • Communication • Treatment plan (personality of the fracture...)
Fracture Discription • Anatomical location - ? joint • Direct / indirect • Fracture configuration • Simple or comminuted • Open or closed • Pathological • Stress fracture • Greenstick fracture
The Rule of A's Radiographs should be described as follows: • Anatomy (eg, proximal tibia) • Articular (eg, extra-articular) • Alignment (eg, first plane) • Angulation (eg, second plane) • Apex (eg, apex pointing medially) • Apposition (eg, 75% or 0%)
Anatomical and Clinical Discreption Epiphysis Physis • Which bone? • Thirds (long bones) • Proximal, middle, distal third • Anatomic orientation • E.g. proximal, distal, medial, lateral, anterior, posterior • Anatomic landmarks • E.g. head, neck, body / shaft, base, condyle • Segment (long bones) • Epiphysis, physis, metaphysis, diaphysis Metaphysis Diaphysis (Shaft) Articular Surface
Anatomical and Clinical Discreption Articular Extension / Involvement • Intra-articular fractures • “Involves the articular surface” • Dislocation • Loss of joint surface / articular congruity • Fracture-dislocation
Comminution / Pattern • Transverse (Simple) • Oblique (Simple) • Spiral (Simple) • Linear / longitudinal • Segmental • Comminuted • Compression / impacted • “Buckle / Torus” • Distraction / avulsion
Displacement, Angulation, Rotation • Displacement • Extent to which Fx fragments are not axially aligned • Fragments shifted in various directions relative to each other • describe displacement of distal fragment relative to proximal Oblique tibial shaft Fx b/w distal & middle thirds; laterally displaced
Displacement, Angulation, Rotation • Angulation • Extent to which Fx fragments are not anatomically aligned • In a angular fashion • describe angulation as the direction the apex is pointing relative to anatomical long axis of the bone (e.g. apex medial, apex valgus) R Tibial shaft Fx b/w prox & middle thirds, angulated apex lateral (apex varus)
Displacement, Angulation, Rotation Angulation Valgus Apex medial Parallel No angulation Varus Apex lateral
Displacement, Angulation, Rotation • Rotation • Extent to which Fx fragments are rotated relative to each other • Convention: • describe which direction the distal fragment is rotated relative to the proximal portion of the bone
Displacement, Angulation, Rotation Rotation • PA view of rotated hip Fx • Greater trochanter perpendicular to film • Normal PA view of hip • Greater trochanter in profile
Displacement, Angulation, Rotation Shortening • Has the fracture caused shortening of the bone involved? • To what extent has shortening occurred?
Intrinsic Bone Quality Normal • Osteopenia • Decr’d density
Intrinsic Bone Quality • Osteopetrosis • Incr’d density Normal
Intrinsic Bone Quality Normal • Osteopoikilosis • Focal areas of incr’d density
Soft tissue involvement • Is the fracture open or closed? • Is associated neurological and or vascular injury present? • Is there muscle damage or compartment syndrome evident?
Open fracture implies communication between external environment and the fracture. • A soft tissue injury complicated by a broken bone.
Components of open fracture • Fracture • Soft-tissue damage • Neurovascular compromise • Contamination • Extent of each component must be assessed individually in order to achieve a comprehensive understanding of the injury, upon which the treatment plan can be based.
Gustilo and Anderson Classification • Model is tibia, however applied to all types of open fractures • Emphasis on wound size • Crush injury assoc with small wounds • Sharp injury assoc with large wounds • Better to emphasize • Degree of soft tissue injury • Degree of contamination
Why use this classification? • Grades of soft tissue injury correlates with infection and fracture healing
Nocosomial infection?!!!! Cover the wounds quickly • Only 8% of infections were caused by the same organism initially isolated in the perioperative cultures • 92% of open fracture infections were caused by bacteria acquired while the patient was in the hospital
Gustilo Classification of Open Fracture • Type I: • Wound is shorter than 1 cm. • It is clean and generally is caused by a fracture fragment piercing the skin (ie, inside-out injury). • This is a low-energy injury.
Gustilo Classification of Open Fracture • Type II: • The wound is longer than 1 cm. • It is not contaminated and without major soft tissue damage or defect. • This is also a low-energy injury.
Gustilo Classification of Open Fracture • Type III: • Wound longer than 1 cm, with significant soft tissue disruption • High-energy trauma resulting in a severely unstable fracture with varying degrees of fragmentation • IIIa: • Sufficient soft tissue to cover the bone without the need for local or distant flap coverage
Gustilo Classification of Open Fracture • Type III: • IIIb: • Extensive soft tissue disruption • Local or distant flap coverage is necessary to cover the bone • The wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound
Gustilo Classification of Open Fracture • Type III: • IIIc: • Any open fracture associated with an arterial injury, which requires repair is considered type IIIC • Involvement of vascular surgeons is generally required
Gustilo Classification of Open Fracture • Type I: • Wound is shorter than 1 cm. • It is clean and generally is caused by a fracture fragment piercing the skin (ie, inside-out injury). • This is a low-energy injury. • Type II: • The wound is longer than 1 cm. • It is not contaminated and without major soft tissue damage or defect. • This is also a low-energy injury. • Type III: • Wound longer than 1 cm, with significant soft tissue disruption • High-energy trauma resulting in a severely unstable fracture with varying degrees of fragmentation • IIIa: • Sufficient soft tissue to cover the bone without the need for local or distant flap coverage • IIIb: • Extensive soft tissue disruption • Local or distant flap coverage is necessary to cover the bone • The wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound • IIIc: • Any open fracture associated with an arterial injury, which requires repair is considered type IIIC • Involvement of vascular surgeons is generally required
I IIIA II IIIB IIIC
Clinical Manifestations of fracture • Edema • Pain and Tenderness • Muscle spasm • Deformity • Ecchymosis • Loss of Function • Crepitation
The six “P”s of musculoskeletal assessment • Pain • on palpation • on movement • constant • Pallor - pale skin or poor cap refill • Paresthesia - “pins and needles” sensation • Pulses - diminished or absent • Paralysis • Pressure
Pre-reading Musculoskeletal Radiographs • 1: Name, date, old films for comparison • 2: What type of view(s) • 3: Identify bone(s) & joint(s) demonstrated • 4: Skeletal maturity (physes: growth plates) • 5: Soft tissue swelling • 6: Bones & joints (fractures & dislocations)
Reading X-rays • Say what it is- • what anatomic structure are you looking at • how many different views are there • Regional Location- • Diaphysis (rule of 1/3) • Metaphysis • Epiphysis including intra and extra-articular • Direction of the fracture line- Transverse, Oblique, Spiral
Reading X-rays • Condition of the bone- • comminution (3 or more parts) • Segmental (middle fragment) • Butterfly segment • Incomplete • Avulsion • Stress • impacted • Deformity • Displacemtent (distal with respect to proximal) • angulation (varus, valgus) • Rotation • shortening (in cm’s) • distraction
Diagnosis of FractureX-RayThe Rule of 2s • Two views: • Anteroposterior (AP) and lateral views of the injured limb (2 views 90° orthogonal to each other) • Two joints: • The joint above and the joint below the injury • Two limbs: • Radiographs of both the injured and noninjured limbs especially in children with epiphyseal-plate injuries • Two times: • 1 prereduction image and 1 postreduction or postfixation image
CT Scanning Not indicated for routine evaluation of common fractures • Preoperative planning for complicated fractures • Provide information about the architecture of fracture lines especially about intra-articular fractures • Evaluate severely fragmented fractures and those involving the epiphyseal segment • Is indicated in assessing the spinal column for injury
Fracture Healing • Primary healing • Non displaced fractures, fractures with compressive fixation across the fracture site • Osteoblasts traverse the fracture site and lay down lamellar bone without forming immature bone when there is direct contact between cortical bone ends
Fracture Healing • Secondary healing • No compression across fracture site, motion can occur • Fracture callus forms to stop motion, stage of consolidation and remodeling