COMMON FRACTURES

1. COMMON FRACTURES Chris Maimaris FRCS FCEM

2. Objectives • To understand the principles of the initial management of closed and compound fractures • To be able to interpret common limb X rays

3. Diagnosis History Examination Ix -Xrays, CT Re-examination of pt prn if in doubt Recognised specific injury Ask for advice Treatment Reduction Retention Rehabilitation Fracture Management

4. Treatment Fractures/Dislocations • Reduction- restore bones +/- joints to normal anatomical position • Retention- Maintain reduced position- until bone union or healing of soft tissues • Perkin’s formula for pop immobilisation • Rehabilitation – restore function: Full range of movements -FROM - and strength

5. Life or Limb Threatening Emergencies • Major pelvic fracture • Exsanguinations • Compartment syndrome • Ischaemia, myoglobinuria, renal failure • Open fracture • Osteomyelitis • Limb injury with vascular injury • Amputation

6. The ‘Ten Commandments of Emergency Radiology’ according to Touquet et al (BMJ 1995): • Treat the patient, not the radiograph • Take history +examination before ordering Xray • Request a radiograph only when necessary • Never look at radiograph without seeing patient, and never treat patient without seeing radiograph • Look at every radiograph, the whole radiograph, - remember the ABCS: alignment/ adequacy, bones, cartilage (joints) and soft tissues.

7. The ‘Ten Commandments of Emergency Radiology’ according to Touquet et al (BMJ 1995): • Re-examine the patient when there is an incongruity between the radiograph and the expected findings • Remember the rule of twos— two views, two joints (above and below the injury), two sides (for comparison), two occasions (may need a follow up x-ray) and two radiographs (compare to a normal radiograph) • Take radiographs before and after procedures • If a radiograph does not look quite right ask and listen: there is probably something wrong. • Ensure you are protected by fail safe mechanisms— establish a quality control system

8. Early Local damage Soft Tissues Nerves Vessels Infection Early general Bleeding Fat embolism Infection-Tetanus, gangrene Fracture Complications • Late Local • Mal-union -Non-union • Avascular necrosis • Osteomyelitis • CRPS-complex regional pain s

9. Wrist X Ray

10. Colles Fracture • 10% of A & E # • Low energy - elderly patient • Fracture of distal radius within 2.5 cm of wrist. • There is # ulnar styloid and characteristic displacement.

11. Reduction Retention Rehab Healing #s Bier’s/Haematoma block/ Sedation MUA reduce # and or dislocation Re-Xray to check POP Back slab position HAS and # clinic F/U UL Child 3/52 Adult 6/52 LL Child 6/52 Adult 6-12/52 Colle’s #

13. Describe this fracture Open/ Compound Mid-shaft left tibia and fibular medial displacement no bony apposition Transverse mid shaft right tibia and fibular

14. TIBIA SHAFT • RESUSCITATION • ANALGESIA • BOX SPLINT • OPEN OR CLOSED • SOFT TISSUES • PULSE • X - RAY

15. Management of Compound fractures/dislocations • Analgesia • Photograph • Avoid further contamination cover • Washout, Debridement etc • Antibiotics/Tetanus prophylaxis • Reduction /Immobilisation • Theatre within 6 hours

17. Clavicle • Commonest site of fracture • Easily diagnosed clinically • One x ray view enough

19. In anterior dislocation diagnosis is usually clear on AP as humeral head moves medially and inferiorly

22. Anterior dislocation of the glenohumeral joint • Clinically usually obvious • X ray is to confirm and rule out accompanying fracture

23. Humeral head is anterior to the Y of the scapula/acromion/coracoid

24. Humeral head is anterior to the Y of the scapula/acromion/coracoid

25. HEAD/ NECK MINIMAL DISPLACED NECK OF HUMERUS OR TUBEROSITY # COLLAR AND CUFF SHAFT SHAFT CHECK RADIAL NERVE AND ARTERIAL SUPPLY U SLAB PLASTER SUPRACONDYLAR ?NEUROVASCULAR STATUS UPPER ARM

27. Elbow X Ray

28. Elbow X Ray • Radiocapitellar line • ? Dislocated radial head

29. Elbow X Ray • Anterior humeral line • ? Supracondylar #

30. Elbow X Ray • Fat pad signs • ? Fracture • Adult ? radial head • Child ? supracondylar

31. Elbow dislocation

32. Elbow Dislocation Check for • coronoid process # • radial head # • epicondylar # in children • ulnar/medial nerve damage • brachial artery damage

33. Elbow dislocations • X rays are normal in ‘pulled elbow’ • Elbow dislocation is usually obvious on x ray • check carefully for avulsions on post reduction film - especially medial epicondyle

34. Pulled Elbow • Age: 1-4- Reduce: • pronation/ flexion manoeuvre • Supination / Flexion

35. Elbow epiphyses in children‘critol’ • Capitellum - appears first • Radial head • Internal Epicondyle (medial) • Trochea • Olecranon • Lat epicondyle • It is the order they appear in that is important, not the age at which they appear

36. SHAFT # ALWAYS EXAMINE & X RAY JOINTS ABOVE AND BELOW # SITE FOREARM FRACTURES

43. Trauma Scaphoid • 80-90% of carpal # • Often difficult to see • Need four views • Follow up1-2 week if normal, Re-Xray

44. Adult Hip X raysusually following fall onto hip • Look for # in • subcapital region • trochanteric area • acetabulum • pubic rami

45. Shenton’s line is disrupted by this # femoral neck

46. Right pubic ramus fracture

47. SUFE – line drawn up femoral neck equally bisects the epiphysis on the left but not the right

48. More clearly seen on this frog view

49. Perthes’ disease – note flattened, ragged appearance of epiphysis on right

50. FEMUR • NECK • ANALGESIA • FAST TRACK TO WARD • SHAFT • O2 / IV NaCl • ANALGESIA • FEMORAL NERVE BLOCK • TRACTION SPLINT NECK SHAFT