T3 L7. Principles of fracture management (BR)(3).pptx

Principles of Fracture Management Prof Benedict Rogers MA MSc PhD MRCGP FRCS(Orth) Consultant Trauma & Orthopaedic Surgeon Honorary Professor, BSMS Trauma and Fractures Trauma and Fractures Trauma and Fractures Save Limb Complications of Surgery Loss of Life Loss of Limb Loss of function...

Principles of Fracture Management Prof Benedict Rogers MA MSc PhD MRCGP FRCS(Orth) Consultant Trauma & Orthopaedic Surgeon Honorary Professor, BSMS Trauma and Fractures Trauma and Fractures Trauma and Fractures Save Limb Complications of Surgery Loss of Life Loss of Limb Loss of function Complications of Surgery • General/Systemic • CVS,RS,GIT,GUS,NS • Specific/Local • • • • • • Infection Dislocation Neurovascular damage Fracture Metalwork failure Operation specific Trauma Acute Management Acute handover ATMIST • • • • • • Age Time Mechanism Injuries (top to toe) Signs Treatment ATLS • Revolutionised the treatment of trauma patients in 1980s • Plane crash in Nebraska in 1976 • Now international system taught in 47 countries What do you do? Save Life What is the ATLS approach?? 1. 2. 3. 4. 5. A B C D E Airway • With cervical spine control • Give oxygen • How do you control the cervical spine? Airway • How do you assess the patency of an airway? • When might the airway be compromised? • What might you need to do? Breathing • And ventilation • What is the difference? • How do you assess this? • What might interfere with breathing? • What might you need to do? Immediately life threatening A & B problems “ATOM FC” •A •T •O •M •F •C Immediately life threatening A & B problems Air Obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade Circulation With haemorrhage control 1. How do you assess this? 2. Classes of shock? Physiology of Shock Tachycardia Decreased pulse pressure Altered conscious level Decreased urine output Reduced BP (late) Circulation Where can you bleed from enough to die quickly? What do you need to do? Tranexamic Acid (TXA) • Adult haemorrhagic shock • 274 hospitals, 40 countries • N=20,211 • Randomised, placebo controlled Save Life Multidisciplinary care vital Anaesthetists, Orthopaedics, General Surgery, Cardiothoracic Surgery, Neurosurgery etc etc Communication essential All “singing from same hymn sheet” Save Limb • Only once life saved and patient stabilised… • What contributes to loss of limb? Save Limb 1. Vessels 2. Nerves 3. Bones 4. Soft tissues/muscles Vascular problems Direct arterial injury What to do? Occlusion of venous outflow How might this occur in a trauma patient? Post – Op 1 Describe Compartment syndrome What is it? How to make diagnosis? What is treatment? Fasciotomy Compartment syndrome What happens if you miss it?? Volkman’s ischaemic contracture Bony injuries Can these lead to loss of a limb? Direct Indirect Don’t miss the diagnosis review all investigations….. Summary Save life Save limb Don’t miss the diagnosis Fracture Management History AMPLE • • • • • Allergies Medications Past Medical Hx Last meal Environment/Event (incl Temp) Specific Fracture History Red Flags • Vessels • Nerves • Soft tissues • Viability • Compartment • Children Fracture Examination • Start at the top, remember ATLS • Listen to the patient • Remember your anatomy • • • • LOOK FEEL (carefully) MOVE (carefully) SPECIAL TESTS (nerves and vessels) Fracture Management Relieve pain • Analgesia • Splint the bone Avoid further damage • • • • Reduce dislocations Straighten bent limbs Re-establish circulation Relieve pressure on nerves close by • Open Fractures......? Fracture Management Investigations • Xrays • Two views • Two joints ?Two times Xray Description • Which bone • Where in the bone • • • • • Intra-articular Epiphysis Physis Metaphysis Diaphysis • What sort of bone • Normal, Pathological How to talk the talk… How you ‘think’ 1. It’s a tibia 2. It the far end of it 3. Its broken 4. It goes into the joint 5. The bits have moved! “This is a ….” 1. Displaced 2. Intra-articular 3. Fracture 4. Of the distal 5. Tibia How to talk the talk… How you ‘think’ 1. It’s a tibia 2. It the far end of it 3. Its broken 4. It goes into the joint 5. The bits have moved! “This is a ….” 1. Displaced 2. Intra-articular 3. Fracture 4. Of the distal 5. Tibia Fracture Pattern Description • Simple • Transverse, oblique, spiral • Comminuted • How many parts? • Displaced • Angulated, translated, burst • Special Types • Greenstick, avulsions Describe this fracture Fracture Management….the basics 1 Reduce 2 Stabilise 3 Rehabilitate Fracture Management….the basics 1 Reduce: closed vs open Correct 1 Length 2 Alignment 3 Rotation Fracture Management….the basics 1 Reduce: 2 Stabilise: External – sling, POP, external fixator Internal – wires intramedullary (nail) extramedullary (plates) Fracture Management • Further Options • Nothing – ie mobilise • Replacement Re Pr me no imu m ce m be re n r ! on 1. Reduce 2. Stabilize Plaster External Fixation Internal Fixation -Intramedullary -Extramedullary 1. Reduce 2. Stabilize Plaster External Fixation Internal Fixation -Intramedullary -Extramedullary Polytrauma Polytrauma Care Damage Control Vs Early Total Care Physiological parameters • Acidosis (Lactate<2) • Hypothermia • Coagulopathy = terrible triad of trauma Non-union – Causes 1. Biological hypovascular 2. Mechanical poor fracture stability Fracture Management • Rehabilitation Essential • Complications of surgery Yes there are!! KISS …..again ‘Primum non nocere’ Summary Do basics well & timely manner Know what (& why) you are doing Take the patient with you Be honest