Principles of management of fractures Flashcards
What is a fracture?
A fracture is a break in the structural continuity of bone.
How can fractures be classified?
- closed or open
- Complete or incomplete
- Displaced or undisplaced
- Impacted or non impacted
- Traumatic, stress or pathological
What is an x-ray used for in fracture investigations?
- Confirmation of diagnosis usually require x-ray
- Assessing other associated bone/joint injuries.
- X-ray is important in planning tx
- Important in checking adequacy of tx
- Assessing progress of tx
- In assessment of radiological union
- Detection of some complications
What are the systemic factors that affect fracture healing?
Age
Nutrition
Anemia
Head injury
Drugs (steroids, anticoagulants,nsaid…)
Clinical features of fractures
- Pain / tenderness
- Swelling
- Loss of function
- Deformity
- Abnormal mobility and crepitus (the palpable or audible crackling/ grinding sensation that occurs when the fractured ends of a bone move against each other or surrounding tissues)
- FEATURES OF ASSOCIATED INJURIES (e.G loss of consciousness, shock numbness, haematuria, vascular injuries….)
- Features of open fractures
What are the Local factors that affect fracture healing?
- excessive mobility
- soft tissue interposition
- poor blood supply
- open fractures
- comminutted fractures
- bone gap (bone loss, distraction,at fixation)
- intact fellow bone
- diseased bone (metabolic,infective,neoplasm)
- type of bone (cancellous or cortical)
- intra-articular fractures
Aside from the early, what are other complications of fractures?
DVT/P.E
Bed sores
Plaster sores and other treatment associstion complications
Myositis ossificans
Muscle wasting
Joint stiffness
Reflex sympathetic dystrophy
Osteoarthritis
What are the Early complications of fracture?
Shock
Vascular injury
Nerve injury
Visceral injury
Compartment syndrome
Fat embolism
Haemathrosis
Infection (tetanus, gas gangrene
Abnormalities of fracture healing include
Delayed union
Malunion
Non-union
Avascular necrosis
Growth disturbance in xdren
What are the 5Rs OF FRACTURE Management?
Resuscitation
Radiological diagnosis
Reduction
Retain or hold the reduction
Rehabilitation
Discuss Resuscitation of a patient with a fracture
Using the atls protocol
A – airway and cervical spine control
Breathing
Circulatory problems
It is important to splint the fractures to make resuscitation effective
- Look for injuries that can kill the patient the fastest
Establish venous access (2 wide bore venous access for fliud and for blood) - Collect blood through a cannula to send to the lab to get a PCV
- Check for tissue perfusion by placing indwelling catheter into bladder to measure urine output
*Give analgesic
Discuss the radiological diagnosis of a patient with a fracture
This is after patient has been resuscitated.
Remember the rule of twos while making request)
2 views: orthogonal view (at a right angle) - anteroposterior and lateral
2 joints: mobilize the joint above and joint below
2 limbs (for comparison in children)
2 occasions
2 injuries (may co-exist e.g femur/pelvis or spine)
Discuss Resuscitation of a patient with a fracture
Using the atls protocol
A – airway and cervical spine control
Breathing
Circulatory problems
It is impt to splint the fractures to make resuscitation effective
Discuss the reduction of a patient with a fracture, what are the types of reduction?
Closed reduction
Manipulation
Traction (skin,skeletal,skull)
Traction by gravity
Open reduction
failed close reduction, displaced intra-articular fractures, Traction fractures e.g patella, olecranon
What is the General indication for closed fracture mx?
- Fractures in children
- Undisplaced fractures
- Poor bone quality e.g osteoporosis
- ‘unfixable’ fractures (from severe communition)
- SYSTEMIC CONTRAINDICATION TO surgery (severe medical illness, severe immunocompromise)
- Severe skin lesions, local skin infections, or other soft-tissue conditions may contraindicate ORIF (Open Reduction and Internal Fixation)
- Psychiatric or personalty disorders
Discuss Retaining the reducton
- Cast splintage (P.O.P, fibreglass)
- CONTINOUS TRACTION (skin or skeletal)
- Functional bracing( 20 )
- Internal fixation
- External fixation
What is the history of Cast splintage?
- Albucassis- used bandage stiffened with egg albumin
- Anthonius mathijsen : a flemish millitary surgeon first impregnated dressing with dehydrated gypsium
- CaSO4.H2O + H2O = CaSO4.2H2O (exothermic rxn)
What are the principles of cast application in fractures?
Immobilize the joint above and the joint below
Safety of the limb
What are the Complications of traction?
muscle atrophy/jt stiffness
DVT/PE
circulatory embarassment (gallow’s traction)
peroneal nerve injury (in external rotated limb)
pin site infection
allergic reaction to ZnO
What are the Complications of cast splintage?
tight cast (compartment syndrome)
loose cast may cause loss of reduction
pressure sores
burns
skin abrasion/laceration
allergic dermatitis
cast window blisters
stiffness, disuse and reflex sympathetic dystrophy.
What is Functional bracing?
For fractures of the femur and tibia
Applicable only to sticky fr actures (3-4wks post injury)
Allows joint motion
Associated with a higher risk of malunion
What are the Indications for internal fixation?
failure of closed method
displaced intra-articular fractures
unstable fractures
fractures associated with poor results with non operative treatment e.g galeazzi, monteggia, avulsion fracture of medial humeral epicondyle, femoral neck
associated neuro-vascular injury
multiply injured pxs
fractures in the elderly pxs
delayed or non-union, malunion
types iii and iv physeal injuries
pathological fractures
what are the Types of internal fixation?
interfragmentary screws
wires (kirschner,cerclage)
plates and screws
intramedullary nails
prosthetic replacement is used where fixation or closed mx is likely to fail e.g intracapsular femoral neck fractures in the elderly.
What are the Complications of internal fixation?
infection
non-union
implant failure
refracture
