Classification and Management of Fractures PDF

Classification of Fractures and Principles of Fracture Management Mohammed Alshehri, MD Orthopedic consultant  Objectives  Know the difference between fracture vs. dislocation vs. sprain  Know signs of fracture and dislocation.  Be familiar with typ...

Classification of Fractures and Principles of Fracture Management Mohammed Alshehri, MD Orthopedic consultant  Objectives  Know the difference between fracture vs. dislocation vs. sprain  Know signs of fracture and dislocation.  Be familiar with types of fracture  How to describe fractures  Principles of fracture management  Open fractures management  Bones may break (called fractures)  bones in joints may become separated from each other (called dislocations)  Tears may occur in ligaments (called sprains)  Tears may occur in Muscles (called strains)  Tears may occur in tendons (called a tendon rupture)  Fractures  A disruption or break in the continuity of the structure of bone  What is this?  How to describe fractures? 1. Describe the radiograph? 2. What type of fracture? 3. Where is the fracture? 4. Is it displaced? 5. Is something else going on?  Joint involvement?  Another fracture?  Underlying bone lesion?  Open vs. close?  Why classify?  Why? Fracture language!!  To speak a common language with other surgeons  Treatment guide  Comparison and prognosis assessment tool Know skeletal anatomy! Bone structures Normal Bone and Normal Ossification Bone Terms Epiphysis Epiphyseal Plate (physis) Metaphysis Diaphysis  Radiological evaluation X-ray Rules of 2  Two views  Two joints  Two times  Two sides  Special views  CT scan vs. MRI  Types of fractures Incomplete vs complete  simple Fractures #Directions of the fracture lines other terms: fracture line not seen ! Impaction, depression, and compression  Comminuted fracture butterfly fracture Comminuted fracture segmental fracture  Uncommon fractures ! Stress and pathologic etiologies Fractures involving the growth plate ! Salter-Harris Classification Salter -Harris Classification Simple fractures alignment & displacement of fragments  Anatomic description – comminution  Comminution is the measure of the number of pieces of broken bone  Example are: non- comminuted or mildly comminuted or severely comminuted  Displacement- translation  Translation is sideways motion of the fracture  Usually described as a percentage of movement when compared to the diameter of the bone.  Displacement - angulation  Angulation is the amount of bend at a fracture.  Described with respect to the apex of the angle or with respect to the direction of distal fragment.  Displacement - shortening  Shortening is the amount a fracture is collapsed expressed in centimeters.  Sometimes called bayonet apposition. Anatomic description of fractures  signs and symptoms of fractures and dislocations  History of injury  Pain and tenderness  Difficulty moving the joint  Swelling and bruising  Deformity  Unnatural movement  Numbness and paresthesias  Wound  Shock  JOINT DISLOCATIONS Definition  A dislocation is a separation of two bones where they meet at a joint. A dislocated bone is no longer in its normal position.  Dislocations may be associated with a periarticular fracture  SUBLUXATION  A subluxation is an incomplete or partial Dislocation.  NOMENCLATURE FOR DISLOCATIONS  Name the JOINT  Name the dislocation by the position of the DISTAL FRAGMENT in relation to the proximal fragment  Add FRACTURE to the name if there is a periarticular fracture.  Add OPEN if a wound communicates with the dislocation  Dislocation & Subluxation PIPJ Subluxation Elbow joint Dislocation. Subluxation : Is an incomplete displacement. Joint dislocations require prompt and effective care in the Emergency Department Shoulder dislocation Elbow dislocation Brachial artery injury in up to 8%  Hip dislocation Typical appearance Traumatic mechanism Knee dislocation  Dislocation  Notice swelling/hematoma  Complications  Popliteal artery ( 10- 30%)!!!  Common peroneal nerve(20-30%) What is this?  WHAT IS A SPRAIN?  A sprain is a joint injury that stretches or tears a ligament  Ligament: the fibrous connective tissue that joins the end of one bone with another.  Trauma Epidemiology – Leading cause of death in the first 4 decades – 150,000 deaths annually in the US – Permanent disability 3 times the mortality rate – Trauma related dollar costs exceed $400 billion annually  Preparation Prehospital Notify receiving hospital Closest appropriate facility Report pertinent information Inhospital Warmed IV solutions Ancillary departments notified Equipment made readily available Hospital personnel protection  Pre hospital information and hand over M.I.S.T Mechanism of injury Injury sustaind or suspected Signs- vital on scene and during transport Treatment initiated  ATLS PROTOCOL Preparation & triage Primary survey Resuscitation Adjunct to primary survey and resuscitation Secondary survey Adjunct to secondary survey Post resuscitation monitoring Reevaluation Definitive care Tertiary survey 1st priority is to save patient’s life Always start with the “ABCDE” approach  Primary Survey ABCDEs of trauma care – A airway and c-spine protection – B breathing and ventilation – C circulation with hemorrhage control – D disability/Neurologic status – E exposure Environmental control Adjunct to primary survey and resuscitation  Secondary Survey AMPLE history – Allergies, Medications, PMH, Last meal, Events Physical exam from head to toe, including rectal exam Frequent reassessment of vitals Diagnostic studies at this time simultaneously – X-rays, lab work, CT orders if indicated – FAST exam  Special Groups Pediatric Same priorities with different amount of fluid and different size of equipment Pregnant women Anatomic and physiologic changes Two patient “treat the mother to treat the fetus”  Elderly Diminished physiologic reserve Comorbidities: heart disease , DM, lung disease Multiple medication use Increased risk of death  Fracture management Aims (A) safe life (B) Safe the limb (c) Safe the function  First Aids Efficient First Aid: This relieves the pain and prevents complications. Safe transport: This help to minimize complications in injures to the spine, fracture of the lower limbs, ribs etc (all fractures should be immobilized immediately ) Back slab Neck collar traction collar and cuff sling Definitive fracture treatment Conservative – Closed, undisplaced – Closed, reducible Operative  conservative Close Reduction : if displaced under G.A or conscious sedation or L.A: traction and counter traction, manual realignment, reverse mechanism of injury. Immobilization : – POP cast , – slab , – Functional braces – traction (fixed or balanced). Immobilization  Traction Application of pulling force to attain realignment – Skin traction (short-term: 48-72 hrs) – Skeletal traction (longer periods)  Conservative treatment Undiplaced or minimally displaced fractures Fractures that can be immobilized and reduced non operatively Patients who are not medically fit Fracture of tarsal or metatarsal bone with less displacement Fractures of the metacarpal bones less displaced Duration of immobilization: upper limb lower limb child 3-4 weeks 6-8 weeks Adult 6-8 weeks 10-12 weeks  Operative ORIF (open reduction internal fixat.) - Pin & wire fixat. - Screw fixat. - Plate & screws fixat. - Intra-medullary fixat. Percutaneous pinning External fixation Indications of internal fixation of the fractures Displaced fractures long bone fractures Intra-articular fractures Unstable fractures Fractures with vascular injuries Fracture neck of femur in adults Fractures with multiple fragments Multiple fractures  Open fracture Break in the skin and underlying soft tissue leading directly into or communicating with the fracture and its hematoma  History Last century, high mortality with open fractures of long bones Early amputation in order to prevent death WWI, mortality of open femur fractures > 70% Gustilo open fracture Classification  Type 1 Open Fractures Wound less than 1 cm, without contamination minimal soft tissue injury Inside-out injury  Type 2 Open Fractures Wound between 1 and 10 cm, mild contamination, moderate soft tissue damage  Type 3 – Subtypes 3A, 3B, 3C – 3A: Adequate soft tissue coverage – 3B: Inadequate soft tissue coverage – 3C: Arterial injury requiring repair  Management of open fracture in ER ABC’s Assess entire patient Careful PE, neurovasc S.T.A.N.D Sterile compressive dressings & Splinting Tetanus tox. Antibiotics Narcotic med (Pain control) Debridement & Local irrigation  The Irrigation Amount Irrigation bags typically contain 3 L of fluid Anglen recommends: – 3L (one bag) for type 1 – 6L (two bags) for type 2 – 9L (three bags) for type 3  Types of fracture stabilization Splint – Good option if operative fixation not required Internal fixation – Wound is clean and soft tissue coverage available External fixation – Dirty wounds or extensive soft tissue injury  Rehabilitation Physiotherapy It essentially consist of muscle Re-education exercise and instructions regarding mobilization of the limb and gait training  Fracture - Complications At time of injury (Immediate) – Haemorrhage – Damage to important internal structures (brain ,heart..) – Skin loss ,Shock ,Nerve damage – COMPARTMENT SYNDROME  Fracture - Complications LATE COMPLICATION Local General Tissue necrosis Deep Vein Thrombosis, Local wound Infection Pulmonary embolism Loss of alignment Osteoarthritis Delayed, malunion and non union Joint stiffness