FRACTURES And other Orthopaedic Disorders Jill Cavaiuolo.
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Transcript of FRACTURES And other Orthopaedic Disorders Jill Cavaiuolo.
FRACTURES
And other Orthopaedic Disorders
Jill Cavaiuolo
Fracture Definition
• Description: A fracture is a medical condition in which a bone is cracked or broken. While many fractures are the result of high force impact or stress, bone fracture can also occur as a result of certain medical conditions that weaken the bones.
CLASSIFICATION OF #
Open fracture (Also called compound fracture.) - the bone exits and is visible through the skin, or a deep wound that
exposes the bone through the skin.
Closed fracture (Also called simple fracture.) - the bone is broken, but the skin is intact.
Complete- the bone is completely broken in two or more pieces
Incomplete-the bone is not broken all the way through
Direction of Fracture LineTransverse
ObliqueSpiral
ComminutedCompression
Categories of Fractures• In a compound fracture, also called an
open fracture, the bone breaks through the skin; it may then recede back into the wound and not be visible through the skin.
Categories of Fractures• In a simple fracture, also called a closed
fracture, the bone breaks but there is no open wound in the skin.
Categories of Fractures• Complete fractures
refer to the way the bone breaks: In a complete fracture, the bone snaps into two or more parts..(i.e. # ulna)
• Incomplete fractures have a bone that breaks, but does not go all the way through.
Fracture Categories
http://www.hughston.com/hha/b_14_2_1a.jpg
Common Fractures
Greenstick - incomplete fracture. The broken bone is not completely separated.
Common Fractures
• Transverse - the break is in a straight line across the bone.
Common Fractures
• Spiral - the break spirals around the bone; common in a twisting injury.
Common Fractures
• Oblique - diagonal break across the bone.
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Common Fractures
• Compression - the bone is crushed, causing the broken bone to be wider or flatter in appearance
http://brighamandwomens.staywellsolutionsonline.com
Other types of Fractures
• An impacted fracture is one whose ends are driven into each other. This is commonly seen in arm fractures in children and is sometimes known as a buckle fracture.
• Other types of fractures are pathologic fracture, caused by a disease that weakens the bones, and stress fracture, a hairline crack.
Examples
Xray Example• This xray indicates a lateral view of an
oblique fracture to the mid humerus.
Closed Oblique Fracture
• This fracture is considered to be mildly displaced.
Types of Fractures• Mildly displaced spiral fractures of the
Tibia and Fibula.
Types of Fractures
• Comminuted and mildly displaced fractures of the distal Tibia and Fibula.
EXAMPLE: A 57 year old 350 lbs. man who puts
significant pressure on his ankle as he walks.
Diagnosis PILON FRACTURE
This is a comminuted fracture of the distal tibia due to axial compression
of the ankle joint. It is frequently associated with a fracture of the distal shaft of the fibula as well.
WARNING
GRAPHIC TRAUMA PICTURE
Open Fractures• A break in the skin
and underlying soft tissue leading into, or communicating with the fracture and its hematoma
WARNING
THE NEXT TRAUMA SLIDE IS VERY GRAPHIC
Open Fracture
REVISION
Define Fracture• Define Open and Closed #• Define Complete or Incomplete #• Give examples of classification based on
the direction of # line.• Define the following types of fractures.
Did you answer that it is a closed comminuted fracture of the femur?
Transverse complete # of Fibula
Compound(open) # of Tibia and Fibula. The tibial break looks oblique, and the fibula appears to be comminuted.
Fractures—Signs and Symptoms• Some clearly present (compound fracture)
or obvious deformity• Swelling, tenderness, altered sensation• Inability to move limb• Crepitus
– Grating sound heard if ends of bone fragments move over e/other
• Pain immediately after injury– Can be delayed if nerve damage in
area• Diagnostic Tests
– X-rays
Fractures- Complications• Muscle spasm
– Due to local pain and irritation– Pulls bone fragments further out of
position– Causes angulation (deformity) and
rotation of bone which can cause more soft tissue damage, bleeding, and inflammation.
• Infections – Tetanus, osteomyelitis– In Compound fractures or when
surgery needed precautions taken (antimicrobials, tetanus booster shot)
# Wrist: Note Swelling in top and bottom picture and deformity in the compound (open) fracture below.
Complications
• Ischaemia– Develops in limb following treatment– Occurs as oedema increases in 1st 48
hrs after trauma and casting.– Can be due to cast becoming too tight.
• The affected part becomes pale, pulseless, painful, paralysed, paraesthetic and 'perishing with cold' ('the 6 Ps').
• Fixed mottling of the skin implies irreversible changes.
• The limb may be red when dependent, leading to a misdiagnosis of inflammation, e.g. gout or cellulitis.
Complications Cont.
Compartment syndrome:
– Develops shortly after fracture when more extensive inflammation (crush fractures)
– Increased pressure of fluid w/in fascia causes severe pain and ischemia or necrosis of muscle
– Pressure effects can be aggravated by cast
Compartments of Lower Leg
Compartment Syndrome
Pressure Release
Compartment Syndrome
• www.residentandstaff.com/issues/articles/2007-03_01.asp
Complications Cont.• Nerve damage
– w/ severe trauma or tearing of periosteum
• Failure to heal (nonunion) or healing of bone w/ deformity (malunion)– Results if bone is not stabilized with
ends closely approximated and aligned• Fractures at or near joint may have long-
term effects– Osteoarthritis or stunted growth
Complications Cont.
• Fat emboli– Risk when fatty marrow escapes from bone
marrow into vein w/in 1st week after injury– More common in fracture of pelvis or long bones,
especially if not well immobilized after injury– Can travel to lungs and cause obstruction,
extensive inflammation, and respiratory distress
Fat Embolism
• Fat Embolism Syndrome– Globules of fat, released from fractured
bone– Fat mixes with platelets
• Emboli travel to lungs, brain, or other areas.
– Clotting cascade activated = petechiae
Fat Embolism Syndrome
• Signs and Symptoms– Dyspnoea– Confusion– Pulmonary complications
– Pulmonary Oedema– ARDS(Acute Respiratory distress
syndrome)– Petechiae-small spots on the skin
Complications-DVT
Closed Fracture Considerations• The energy of the
injury• Degree of
contamination• Patient factors• Additional injuries
Fractures—Treatment • Management of Pain,nausea etc.• Cleaning the wound if open-may be done in
theatre• Immediate splinting and immobilization• Reduction of bones to restore normal
positionClosed reduction: exerting pressure and tractionOpen reduction: requires surgery
• Pins, rods, plates, screws
Splinting and Immobilization
– Casting with plaster or fiberglass, and splints .
Closed Reduction Traction
Application of force or weight pulling on limb that is opposed
by body weightForce maintains alignment of
bones, prevents muscle spasms, and immobilizes the
limb
Open Reduction
• Internal fixation of Radius
External Fixation
• This is a patient treated with an external fixator, which is used to treat fractures that are too unstable for a cast. You can shower and use your hand gently with the external fixator in place.
Internal FixationFractured Pelvis
Internal Fixation
Trans articular pin fixation
Fractures—Pathophysiology: Factors Affecting Healing Process
• Amount of local damage to bone and soft tissue– Major determining factor– Prolonged inflammation or extensive
damage to bv or periosteum impairs healing
• Amount of realignment and approximation– Closer the ends of the bones are, the
smaller the gap to fill, the faster the healing process
• Secondary problem – Foreign material or infection delays
healing
Factors Affecting the Healing Process
• Numerous systemic factors– Delayed healing in elderly pts w/
circulatory problems, diabetes mellitus, anaemia, nutritional deficits, steroid therapy.
Bone Healing• As soon as a fracture occurs, the body
acts to protect the injured area, forming a protective blood clot and callus or fibrous tissue.
• New "threads" of bone cells start to grow on both sides of the fracture line. These threads grow toward each other.
• The fracture closes and the callus is absorbed.
Fractures—Pathophysiology of Bone Repair
Nursing Management
General Observations for pins, traction and casts include:
• Skin inspection hourly• Neurovascular observations ½ -1 hourly• Limb alignment• Limb exercises• Signs of infection –warmth, swelling, pain,
odour, discharge
Nursing Management
• Elevation• Monitor Pt. pain and comfort• Remind Pt. of injured limb and positioning
etc.• Check bed positioning of Pt to ensure
traction is functioning.• Check equipment i.e. pulleys, pins etc.• Pts. with traction must never have weight
bags lifted randomly.
Plaster Management
• Maintain cast integrity• Turn Pt. 1-2 hrly• Use palms when handling wet plaster• Do not cover wet cast-allow to dry• Check cast ooze and outline• Educate Pt. to not shove anything inside of
cast e.g. knitting needles
Plaster Management
• Do not use blow dryer to dry cast• Cast will heat when drying• Cast is heavy• Observe skin around cast edge, skin
breaks can lead to infection
A Case History
A 24 year old right hand dominant man sustained a compound fracture of his right forearm as a teenager. He had a deep infection that required part of the bone to be removed. His right wrist was severely deformed and x rays showed bone loss and a non-union of the fracture.He had surgery that reconstructed his bone, rehab. and he returned to work as a full time construction worker.
http://www.theuniversityhospital.com/limblength/tech.htm
A Case History
Other Disorders
Sprains and StrainsSprain. A sprain is a stretching or
tearing of ligaments. Ligaments are tough bands of fibrous tissue that
connect one bone to another. Common locations for sprains are
your ankles and knees. Strain. A strain is a stretching or
tearing of muscle or tendon. People commonly call strains "pulled" muscles. Hamstring and back injuries are among the most
common strains
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Sprains and Strains• Both easily torn when excessive force exerted
on a joint• Avulsion
– Ligaments or tendons completely separated • Painful, tenderness, discoloration (due to
haematoma formation)• Strength and range of movement of the joint are
limited• Diagnosis: X-ray,scans etc. to rule out fracture
and to note extent of damage
Sprains and Strains Healing
• Tear, then inflammation, then granulation tissue
• Collage fibers form to create links w/ existing tissue
• Eventually healing mass bound together w/ fibrous tissue
• Healing 6 weeks• Severe damage requires surgery
Dislocation• Separation of 2 bones at a joint
– Loss of contact between articulating bone surfaces
– Usually one bone out of position, other normal– Eg. humerus displaced from scapula
• Subluxation– Bone only partially displaced w/ partial loss of
contact between surfaces• Causes considerable soft tissue damage
– Also damage to ligaments, nerves, bv as bone pulled away from joint
– Inflammation and bleeding– Severe pain, swelling, tenderness
Dislocation
• Diagnosis confirmed by X-ray• Treatment
– Reduction to dislocated bone, immobilization, therapy to maintain joint mobility
– Healing is slow if ligaments and soft tissue extensively damaged
History After breaking a hip, a 70 year old
woman undergoes hip replacement surgery. After 5 days she comes back
with severe hip pain. Diagnosis
TOTAL HIP PROSTHESIS SUPERIOR DISLOCATION
References
Fracture classification/sprains and strains• www.mayoclinic.com• Radiology Web Site - McGill University
http://sprojects.mmi.mcgill.ca/icmcradiology/index.aspx• Brigham and Women’s Hospital Types of Fractures
http://brighamandwomens.staywellsolutions online.com