General Aspects of Fractures and Dislocations PDF

Misr University for Science and Technology Orthopaedics Department S.Surgery 601 Course General As pe ct s of Fract ure s and D is lo cat io ns Fracture: A fracture is a complete or incomplete break in the continuity of a...

Misr University for Science and Technology Orthopaedics Department S.Surgery 601 Course General As pe ct s of Fract ure s and D is lo cat io ns Fracture: A fracture is a complete or incomplete break in the continuity of a bone or a cartilage resulting from the application of excessive force. Dislocation: Disruption of the normal articulation between two bones i.e.: displacement of one or more bones at a joint Subluxation: The abnormal movement of one of the bones that comprise a joint. Not a true dislocation. A partial dislocation.  Fractures Aetiology Traumatic (Normal Bone): Tubular Bone: Direct and Indirect Cancellous Bone: Compression and Traction Pathological (Abnormal Bone): Integrity of underlying bone is abnormal History is often minimal trauma Local Causes: OM, Tumours, and Cysts Generalized Causes: e.g. Osteoporosis Stress fracture  Fractures How to diagnose Fracture?? Clinical Diagnosis A- History of trauma B- Symptoms: following history of trauma, includes: pain, loss of function and deformity C- Signs Swelling Tenderness Abnormal mobility Deformity Loss of function Crepitus???!!! D- Neurovascular examination of the limb  Fractures How to diagnose Fracture?? Radiological Examination A- The fractured bone B- Joint above and Joint below C- In two planes at right angle to each other. D- Special views when needed.  Fractures Fracture Discription According to site of fracture: Diaphyseal Metaphyseal Epiphyseal Intra-articular  Fractures According to the Fracture Complete : two cortices Incomplete : only one cortex Usually in children Greenstick – break on convex side Adults: e.g: Stress fx abnormal stress to normal bone  Fractures According to Fracture Line Orientation, Location: Transverse Oblique Spiral Comminuted  Fractures According to pattern of Displacement Distraction Impaction Over-riding  Fractures According to pattern of Displacement (contd.) Rotation Translation Angulation  Fractures According to Soft tissue damage Simple or closed fracture : skin intact Compound or open fracture: Fracture in which the fracture hematoma communicates With the outer air. - Compound from with-in - Compound from With-out  Fractures How to manage a Fracture?? General Management A- Air wayControl blood loss (open fractures) B- Breathing C- Circulation D- Disability E- Associated injuries, e.g. Internal hge Visceral injury F- Tetanus, gas gangrene, and fat embolism  Fractures How to manage a Fracture?? (contd.) Local Management A- Correction of displacement B- Stabilize the correction C- Rehabilitate the limb  Fractures Local Management A- Correction of the displacement Why??: to correct the deformity at the fracture site. When??: As early as possible Acceptance of reduction: side to side= 50% no rotation, no angulation How??: Closed: Manipulation under GA against deformity Open: Failure of closed reduction multiple trauma associated neurovascular Intra-articular fracture nonunion and malunion Pathological fractures  Fractures Local Management B- Stabilize Fracture 1- External : - P.O.P: splint and cast - Traction: Skin and Skeletal - External fixator 2- Internal fixation  Fractures How to manage a Fracture?? (contd.) Local Management B- Stabilize Fracture 1- External splinting with P-O-P (Plaster of Paris) Include joint above & joint below for stability Advantages: - Safe - No equipments required Disadvantages: - Joint stiffness - Muscular atrophy - Inability to maintain perfect reduction - ? Compartment syndrome  Fractures How to manage a Fracture?? (contd.) Local Management B- Stabilize Fracture 2- Traction - Skin  Fractures How to manage a Fracture?? (contd.) Local Management B- Stabilize Fracture 2- Traction - Skeletal  Fractures How to manage a Fracture?? (contd.) Local Management B- Stabilize Fracture 3- External Fixation: In compound fracture  Fractures How to manage a Fracture?? (contd.) Local Management B- Stabilize Fracture 4- Internal Fixation: Wires, Plate and screws, Intrameduallry nail, Interlocking nail and K-wires with or without tension bandage Advantages: - Accurate and stable reduction - Early mobilization of the patient  Fractures How to manage an OPEN Fracture?? What is the problem with the Open Fracture?? Possibility of INFECTION What is my target?? To Eliminate INFECTION  Fractures How to manage an OPEN Fracture?? How to eliminate the Infection?? - Under General Anesthesia - Thorough cleaning of wound and Deep fascia is widely opened - Foreign bodies, necrotic tissue or damaged muscles should be removed. - Soft tissue injury is dealt with - Bleeding points are tied (except large vessels) - Skin not be closed - Fracture is stabilized either by P-O-P or external fixator NO INTERNAL FIXATION - Prophylactic antibiotics and prophylaxis against tetanus and gas gangrene  Fractures How to manage an OPEN Fracture?? How to eliminate the Infection?? - Fracture is stabilized either by P-O-P or external fixator NO INTERNAL FIXATION - Prophylactic antibiotics and prophylaxis against tetanus and gas gangrene  Fractures Complications of fractures: General Complications Local Complications: Early Local complications Late Local Complications Associated Injuries  Fractures Complications of fractures: General Complications 1- Shock: Neurogenic Hypovolaemic 2- Fat embolism 3- Complications of prolonged decumbency Respiratory complications Deep veinous thrombosis Urinary calculi Bed sores 7- Tetanus and gas gangrene (in open fractures)  Fractures Complications of fractures: Early Local Complications 1- Skin injury 2- Vascular injury: injury - Kink – compression 3- Nerve injury: axonotemesis – neurotemesis 4- Tendon or muscular injury 5- Infection 6- Avascular necrosis 7- Visceral complications  Fractures Fracture Union Terminology Callus: new bone formed at fracture site Remodeling: reforming of callus along lines of stress to approximate normal contour Delayed union: Fracture fails to heal in usual time but will heal if cause of delayed healing is corrected. Non-union: failure of fracture fragments to unite and healing process has stopped Mal-union: fracture fragments have healed with angular or rotational deformity that impairs function  Fractures Complications of fractures: Late Local Complications (1) Malunion: - Cosmetic - Function (2) Delayed union & nonunion: Impaired blood supply Improper positioning Soft tissue interposition Infection Soft tissue damage Pathological fracture  Fractures Complications of fractures: Late Local Complications (3) Sudek’s atrophy: Osteoporosis, swelling of soft tissue, vascular stasis, pain and joint stiffness complicating a fracture. Unknown etiology ? Vascular stasis ? Lack of physiotherapy  Fractures Complications of fractures: Late Local Complications (4) Myositis ossificans: Ossification of the subperiosteal haematoma or hetrotropic bone formation in the muscle. common in dislocation of elbow, shoulder or hip Treatment: immobilization no massage no surgical removal +/- Radiotherapy  Fractures Complications of fractures: Late Local Complications (5) Joint stiffness: prolonged immobilization After intra-articular fracture Early mobilization is important (6) Growth disturbance: If the growth plate was injured (physis) (7) Osteoporosis: Prolonged non-use of the limb