Introduction to fractures and traumaIntroduction to fractures and trauma

Principles of fracturesPrinciples of fractures

FractureFracture : : it is break in the structural continuity ofit is break in the structural continuity of

the bonethe bone. . It is of two main typesIt is of two main types: :

11 - -simple fracture ( closed )simple fracture ( closed ). .

22 - -compound fracture (open ) .i.e. associated with woundcompound fracture (open ) .i.e. associated with wound

connecting it to the externalconnecting it to the external

environmentenvironment. .

How fracture happenHow fracture happen: :

11 - -single traumatic incidentsingle traumatic incident. .

22 - -repetitive stressrepetitive stress. .

33 - -abnormal weakening of the bone ( pathological fracture )abnormal weakening of the bone ( pathological fracture ). .

In single traumatic incident the bone sustained sudden and excessive In single traumatic incident the bone sustained sudden and excessive force which may be direct or indirectforce which may be direct or indirect: :

In direct force the bone break at the point of impact ; while in 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 force the bone is break at distant from the site of force where it appliedapplied. . The force which break the bone is of different typesThe force which break the bone is of different types: : AA- twisting force . - twisting force . BB- bending force- bending force. . CC-compression force . -compression force . DD- tension force- tension force. .

Each of them influence the shape of the fracture which is either Each of them influence the shape of the fracture which is either spiral ,oblique , transverse , or fracture with butter – fly segmentspiral ,oblique , transverse , or fracture with butter – fly segment. . all this is applied to the long bonesall this is applied to the long bones. . So So the fractures either the fractures either complete or incompletecomplete or incomplete: : Complete could be Complete could be ttransverseransverse , , oblique , spiraloblique , spiral , or , or comminutedcomminuted. . And incomplete could be And incomplete could be green stickgreen stick or or compressioncompression fracture fracture. .

Types of fracture displacementTypes of fracture displacement

Fracture healingFracture healing : : immobilization of the fracture is not immobilization of the fracture is not

mandatory for fracture healing ; themandatory for fracture healing ; the

splinting of the fracture to ensuresplinting of the fracture to ensure: :

11 - -pain relief . 2- union take place in good positionpain relief . 2- union take place in good position. .

33 - -early movement and return to functionearly movement and return to function. .

Steps of fracture healingSteps of fracture healing: : 11 - -tissue destruction and haematoma formationtissue destruction and haematoma formation. .

22 - -acute inflammatory reaction and cellular proliferationacute inflammatory reaction and cellular proliferation. .

33 - -callus formation (step of union)callus formation (step of union). .

44 - -consolidationconsolidation. .

55 - -remodelingremodeling. .

Time tableTime table: : For fracture healing the time change according to age , blood supply , For fracture healing the time change according to age , blood supply , type of the fracture ……etctype of the fracture ……etc..

Perkin`s time tablePerkin`s time table is very simple table to asses that time is very simple table to asses that time: :

Spiral or oblique fracture in the upper limb unite in 3 weeksSpiral or oblique fracture in the upper limb unite in 3 weeks. .

Transverse fracture in the upper limbs unite in 6 weeksTransverse fracture in the upper limbs unite in 6 weeks. .

For consolidation multiply by 2For consolidation multiply by 2. .

In the lower limbsIn the lower limbs: :

Oblique or spiral fracture need 6 weeks for unionOblique or spiral fracture need 6 weeks for union. .

Transverse fracture need 12 weeksTransverse fracture need 12 weeks. .

For consolidation multiply by 2For consolidation multiply by 2. .

Clinical features of the fractureClinical features of the fracture: : A – A – symptomssymptoms: :

11 - -history of trauma followed by inability to use the injuredhistory of trauma followed by inability to use the injured

limb ; if the trauma is simple and weak force we suspectlimb ; if the trauma is simple and weak force we suspect

pathological fracturepathological fracture. .

22 - -pain . 3- brusing . 4- swelling . 5- deformitypain . 3- brusing . 4- swelling . 5- deformity. .

B – B – signssigns: :

11 - -swelling . 2- Bruising . 3- deformity . 4- tendernessswelling . 2- Bruising . 3- deformity . 4- tenderness. .

55 - -crepitus . 6- loss of functioncrepitus . 6- loss of function . .

X – rayX – ray : : it is mandatory for diagnosis of fractures it is mandatory for diagnosis of fractures. .

Role of twosRole of twos: :

11 – – two viewstwo views. .

22 – – two jointstwo joints. .

33 – – two limbstwo limbs. .

44 – – two injuries . e. g. fracture calcaneumtwo injuries . e. g. fracture calcaneum. .

. .55 – – two occasions e.g. fracture scaphoidtwo occasions e.g. fracture scaphoid

66 - -two tissuetwo tissue. .

Special imagingSpecial imaging::

11 - -tomography . tomography . 22- C.T. - C.T. 33- MRI . - MRI . 44- bone scan- bone scan . .

Treatment of closed fractureTreatment of closed fracture: : A A – the general treatment is the first consideration i. e– the general treatment is the first consideration i. e..

the air way patency , breathing and circulationthe air way patency , breathing and circulation. . BB – treatment of the fracture itself : this include – treatment of the fracture itself : this include: :

11 - -reductionreduction . . 22 - -holdingholding. .

33 - -physiotherapy and rehabilitationphysiotherapy and rehabilitation. .

11 - -reduction of the fracturereduction of the fracture: : It should be taken in the first 12 hours from the trauma , because the It should be taken in the first 12 hours from the trauma , because the oedema and swelling make the reduction difficult after that timeoedema and swelling make the reduction difficult after that time. . Two types of reductionTwo types of reduction: :

11 - -closed reduction ( by manipulation )closed reduction ( by manipulation ). . 22--open reduction ( by surgical approach )open reduction ( by surgical approach ). .

Open reduction is indicated inOpen reduction is indicated in: :

11 - -when close reduction failwhen close reduction fail. .

22 - -when there is large articular fragment need accuratewhen there is large articular fragment need accurate

reductionreduction. .

33 - -for traction fractures in which the fragments are heldfor traction fractures in which the fragments are held

apartapart. .

Holding of the fracturesHolding of the fractures : by : by: :

11 - -continuous tractioncontinuous traction. .

22 - -cast splintage ( plster of paris P.O.P)cast splintage ( plster of paris P.O.P). .

33 - -functional bracingfunctional bracing. .

44 - -internal fixationinternal fixation. .

55 - -external fixationexternal fixation. .

TractionTraction : types of traction : types of traction: : 11 - -traction by gravitytraction by gravity : this is used only in upper limb .e.g hanging cast : this is used only in upper limb .e.g hanging cast. .

22 - -skin tractionskin traction : it is available in special kit , it is used : it is available in special kit , it is used mainly in the lower limbmainly in the lower limb. .

33 - -skeletal tractionskeletal traction. . Skin tractionSkin traction

Principle of it's usePrinciple of it's use: : 11 - -applied distal to the fracture siteapplied distal to the fracture site. .

22 - -weight used is 10% of the body wt. and not more than 5 kg , if we need more than 5 kgweight used is 10% of the body wt. and not more than 5 kg , if we need more than 5 kg then we use skeletal tractionthen we use skeletal traction . .

33 - -removal of the hair before applicationremoval of the hair before application . . Indication of skin tractionIndication of skin traction: :

11 - -used in fractures of the lower limbs vertebras and pelvisused in fractures of the lower limbs vertebras and pelvis. . 22 - -in dislocations of the lower limbsin dislocations of the lower limbs. .

33 - -for resting of the limb e.g. in arthritis , osteomyelitisfor resting of the limb e.g. in arthritis , osteomyelitis, , septic arthritis , irritable hip etcseptic arthritis , irritable hip etc.…….……

44 - -in treatment of back achein treatment of back ache. .

Hanging cast/skin Hanging cast/skin traction/thomas splinttraction/thomas splint

Skin traction kitSkin traction kit

skin tractionskin traction

Complication of skin tractionComplication of skin traction: : 11 - -allergy to the adhesive material of the plaster lead toallergy to the adhesive material of the plaster lead to

ulceration of the skinulceration of the skin. . 22 - -compression of the vessels lead to compartmentcompression of the vessels lead to compartment

syndromesyndrome. . 33 - -compression of the nerves lead to neuropraxiacompression of the nerves lead to neuropraxia. .

44 - -excessive traction (when use over wt.) lead to non unionexcessive traction (when use over wt.) lead to non union55 - -failure of the kitfailure of the kit. .

33 - -skeletal tractionskeletal traction: : Pin is inserted distal to the fracture site usually behind the tibial tuberosity or 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 wtlower femoral condyles , the wt. used is one six (1/6) of the body wt. .. .ComplicationComplication : 1- broken of the pin . 2- pin tract infection : 1- broken of the pin . 2- pin tract infection. .

33 - -over (excessive ) tractionover (excessive ) traction. .

Skeletal tractionSkeletal traction

Methods of tractionMethods of traction: : AA- fixed traction e.g. Thomas splint- fixed traction e.g. Thomas splint. . BB- balanced traction ( over pulleys )- balanced traction ( over pulleys ). . CC- combined traction- combined traction. . DD- counter traction- counter traction. .

Cast splintage (p.o.p)Cast splintage (p.o.p): : Plaster of Paris is calcium sulphate hemihydrates , it is very safe and easily used in Plaster of Paris is calcium sulphate hemihydrates , it is very safe and easily used in

holding of the fracturesholding of the fractures. . Principles of using p.o.pPrinciples of using p.o.p: :

11 - -in acute fractures , use the p.o.p in form of slabs to avoidin acute fractures , use the p.o.p in form of slabs to avoid compartments syndromecompartments syndrome. .

22 - -it should involve the joint below and the joint above of the fractureit should involve the joint below and the joint above of the fracture. . 33 - -never applied directly on the skin (use cotton or any other material)never applied directly on the skin (use cotton or any other material). . 44 - -it should never be done too tight or too loose , too heavy or too lightit should never be done too tight or too loose , too heavy or too light. .

Balanced traction//counter tractionBalanced traction//counter traction

Counter traction//gallos tractionCounter traction//gallos traction

Plaster of parisPlaster of paris