An Overview on Fractures Care

Dr. Rashidi AhmadMD USM, MMED USM, FADUSM

Lecturer/EmergentistUSM Health Campus

POP application course18th December 2006

Objectives

• To increase an awareness the importance of appropriate care of fracture

• To increase understanding on fracture management

• To gain more knowledge & skill – to make right decision & to perform the proper action

Outline

• Understanding fractures• Describing fractures based on clinical

presentations & radiological features• Principles of fracture management

Trauma patient is an injured person who requires timely diagnosis and treatment of actual or potential injuries by a multidisciplinary team of health care professionals, supported by the appropriate resources, to diminish or eliminate the risk of death or permanent disability.

Europian Trauma Life Support

Fracture?

• A fracture is a disruption in the integrity of a living bone involving injury to bone marrow, periosteum, and adjacent soft tissues.

How fractures occur?

• Typical fractures• Pathologic fractures• Stress fractures

Pathologic #

Lytic lesion

March/stress fracture

Life threatening fractures

• Le Fort II/III fracture & bilateral mandible fracture with airway compromised

• Upper cervical fracture & flail chest with impaired ventilation

• Pelvic & open fractures with vascular injury/shock• Untreated multiple long bones fracture with fat

embolism• Depressed skull fracture with extradural bleeding

Fat embolic syndrome

Pelvic injuries with intrabdominal injury & shock

Limb threatening

• Fractures with Compartmental Syndrome @ Volkmann’s ischemia

• Fractures with neurovascular injuries/ avascular necrosis

• Open fractures with infection

Compartmental syndrome

Volkmann’s ischemic contracture

Avascular necrosis

Osteomyelitis

Factors affecting fracture healing

• The energy transfer of the injury

• The tissue response– Two bone ends in opposition or compressed– Micro-movement or no movement– BS (scaphoid, talus, femoral and humeral head)– NS– No infection

• The patient• The method of treatment

Goals of fracture treatment• Restore the patient to optimal functional state

• Prevent fracture and soft-tissue complications

• Get the fracture to heal, and in a position which will produce optimal functional recovery

• Rehabilitate the patient as early as possible

Prehospital care• First aid principles• Preliminary splinting/sling of the injured

extremity - reduces pain- reduces damage to nerve & vessels- reduces risk of conversion to open fracture- facilitates transportation & x-ray taking.

Principles Of Splinting

• Apply dry sterile compression dressing to all open wounds

Principles Of Splinting

• Incorporate one joint above and one joint below the fracture

Types Of Splints

• Wooden Splints• Metal Wire / Frame Splints• Air Splints• Vacuum Splints• MAST suit

Post-Splinting Care

Prehospital reduction

• Prehospital reduction of deformity – by advice of physician

• Obvious fracture along the shaft of a long bone with a neurovascular deficit –longitudinal traction

• Deformity near a joint – possibility of dislocation

Careful history

• Precise MOI• Listen carefully to the patient’s symptoms• Why?

- Pain of fracture may be referred to another area- Specific x-ray view is indicated by proper history- Some injuries may not be radiologically apparent on the 1st day

High-energy injury

Low energy injury

Dashboard fracture

Chance # @ lap seat belt #

Physical examination

• Inspection for swelling, discoloration, deformity

• Assessment of active & passive ROM of the joints proximal & distal to the injury

• Palpation for tenderness• Verification of neurovascular status

Radiologic evaluation

• X-ray is an important adjunct• Ordered based on Hx & PE• 2 views – AP & lateral• 2 joints – above & below the shaft

fracture• In children with injury near the joint –

bilateral x-rays for comparison• Repeat x-rays after 1 – 2 weeks to show

callus in doubtful fractures

Describing fractures• Open versus closed• Location of the fracture• Orientation of the fracture line• Displacement & separation• Angulation• Shortening• Rotational deformity• Fracture – dislocation/subluxation• Salter fractures• Fragmentation• Soft tissue involvement

Close #

Open #

Midshaft #

Distal third #

Intertrochanteric #

Subcapital #

Location of fracture

Subtrochanteric #

Neck #

Near the head #

Head #

Supracondylar #

Lateral condyle #

Intercondylar #

Orientation of the fracture line

Torus #

Greenstick #

Bowing #

Displaced & separation

Minimally displaced distal radius fracture

Comminuted proximal- third femoral fracture with significant displacement

Angulation – amount & direction

Shortening

Rotational deformity

Bennet’s # dislocation

Monteggia’s #

Galeazzi’s #

Fracture - dislocation

Salter Harris classification

I S = SLIPPED/separated

II A = ABOVE

III L = LOWER

IV T = THROUGH/together

V R = RAMMED/ruined

Salter Harris Type I

Salter Harris Type II

Salter Harris Type III

Salter Harris Type IV

Salter Harris Type V

Rolando #

Barton’s #

Intraarticular fracure

Fragmentation

- A multi-fragmentary fracture: several breaks (>2 fragments) in the bone

- Wedge fractures: spiral (low energy) @ bending (high energy

- The complex multi-fragmentary fracture: segmental fracture in which there is no contact between the proximal & distal fragments, no bone shortening.

- Simple fractures are spiral, oblique, or transverse.

The Muller AO Comprehensive Classification of Fractures

A multi-fragmentary fracture

Wedge fractures

Soft tissue involvement

• Minor / Grade I - small punctate wound <1 cm a/w low velocity trauma. Minimal soft tissue injury. No crushing. No comminution.

• Moderate / Grade II – extensive wounds with relatively little soft tissue damage, and only moderate crushing or comminution.

• Major / Grade III - wounds of moderate or massive size with considerable soft tissue injury and/or foreign body contamination:• III A - sufficient soft tissue to cover the fracture• III B - insufficient tissue to cover the fracture; also periosteal

stripping and severe comminution• III C - arterial damage requiring repair. Degree of soft tissue

damage not considered

Gustilo. Current Concepts: the management of open fractures. JBJS (1990); 72A; 299-304

Crush injury

Degloving injury

Bomb blast injury

Gunshot #

General management of patients with fracture

• Life saving measures - Primary & secondary survey- Emergency orthopaedic involvement

–Life saving–Complication saving

Cont…

• Emergency orthopedic management- Control of pain & swelling- Keep NBM if GA @ PCS is required- Reducing fracture deformity- Tetanus prophylaxis- Irrigation & debridement- Antibiotic prophylaxis

• Conservative vs surgical management• Monitoring of fracture• Rehabilitation & Rx of complications

Emergency orthopaedic management

• Life saving measures – Reducing a pelvic fracture in haemodynamically

unstable patient– Applying pressure to reduce haemorrhage from

open fracture

• Complication saving– Early and complete diagnosis of the extent of

injuries– Diagnosing and treating soft-tissue injuries

Diagnosing the soft tissue injury

• Skin- Open fractures, degloving injuries and ischaemic necrosis

• Muscles– Crush and compartment syndromes

• Blood vessels– Vasospasm and arterial laceration

• Nerves– Neurapraxias, axonotmesis, neurotmesis

• Ligaments– Joint instability and dislocation

Treating the soft tissue injury

• All severe soft tissue injuries………require urgent treatment

– Open fractures , Vascular injuries, Nerve injuries, Compartment syndromes, Fracture/dislocations

• After the treatment of the soft tissue injury the fracture requires rigid fixation

• A severe soft-tissue injury will delay fracture healing

Treating the fracture • Purpose: to reduce, hold & maintain the # in a suitable

alignment

• Does the fracture require reduction? Displaced?

• Methods: CMR method by ACCROCHAGE and continuous traction (skin & skeletal traction)

• What is acceptable # alignment?

• Consider: age, site, weight bearing, shortening, angulation & rotation

Risk benefit

Operative Non-operative

Rehabilitation Rapid SlowRisk of joint stiffness Low PresentRisk of malunion Low PresentRisk of non-union Present PresentSpeed of healing Slow RapidRisk of infection Present LowCost ? ?

Treating the fracture • How are we going to hold the reduction?

– Semi-rigid (Plaster)– Rigid (Internal fixation)

• What treatment plan will we follow?– When can the patient load the injured limb?– When can the patient be allowed to move the

joints?– How long will we have to immobilise the fracture

for?

Indications for operative treatment

• General trend toward operative treatment last 30 yrs

– Improved implants and antibiotic prophylaxis, use of closed and minimally invasive methods

• Current absolute indications:– Polytrauma, displaced intra-articular fractures– Open #’s, #’s with vascular injury or compartment

syndrome– Pathological #’s, Non-unions

Indications for operative treatment

• Current relative indications:-– Loss of position with closed method– Poor functional result with non-anatomical

reduction– Displaced fractures with poor blood supply– Economic and medical indications

When is the fracture healed?

• ClinicallyUpper limb Lower limb

Adult 6-8 weeks 12-16 weeksChild 3-4 weeks 6-8 weeks

• Radiologically– Bridging callus formation– Remodelling

Rehabilitation

• Restoring the patient as close to pre-injury functional level as possible

• Approach needs to be:-

–Pragmatic with realistic targets–Multidisciplinary: Physiotherapist,

Occupational therapist, District nurse, GP, Social worker

Summary

• Fractures are a/w mortality & morbidity• Fractures care starts from the onset till fully

recover• Primary survey + resuscitation are the

PRIORITY• Do not underestimate the benefit of

reassurance, pain management & splinting• Multidiscipline approach

Final message

Dr. Rashidi AhmadMD USM, MMED USM, FADUSM

Pensyarah/Pakar Perubatan kecemasan & TraumaJabatan perubatan Kecemasan

Pusat Pengajian Sains PerubatanUSM Kampus Kesihatan, Malaysia

shidee_ahmad@yahoo.com+609 7663244