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
What are the Indications for external fixation?
open fractures
unstable pelvic fractures
infected fractures/ non union
fractures associated with neuro-vascular injury
fractures associated with burns
floating knees
fractures associated with bone loss
What are the Complications of external fixation?
damage to soft tissue structures
pin-track infection
overdistraction
What is the Treatment of open fracture?
wound debridement
antibiotic and tetanus prophylaxis
stabilization of the fracture
early wound cover
What are the indications for an amputation?
Severe open fractures with associated vascular injuries requiring repair (type IIIC) when the injury cannot be repaired or the
The limb is so severely crushed that minimal viable tissue remains for revascularization.
There is irreversible associated soft tissue injury and neurologic damage that will result in final function worse than that provided by a prosthesis.
What is an avulsion?
When tissues cannot be brought together, tissues are detached from their primary site
What is a crush injury?
Damage to 2 or more vital tissues or limbs (severe damage, to bones, muscles or vasculature), muscles are severly contused with increase loss of myoglobins which can cause kidney failure if they get to the kidneys
What is a degloving injury?
Circumferential detachment of subcutaneous tissue from the periosteum (a severe injury)
Difference between an open and closed fracture?
Open fracture: communication between fracture hematoma and external environment
Closed fracture:
What is the significance of soft tissue envelope?
These are all the tissues that surround the bone, if breeched, there will be communication between bone and soft tissue
Risk of bacteria within a hematoma
It can cause osteomylitis
How do pathologcial fractures occur?
They occur within a previosuly diseased bone or progressed from previous trauma
What must be included in taking the history of a fracture?
- Pain
* S: area of fracture
* O: sudden in onset
* C: sharp
* R: doesn’t radiate unless it invloves nerve damage
* A: Relievd when at rest
* E: worsened by movement - Swelling (due to hematoma or inflammarion)
* knee and pelvic fractures are more prone to swelling
* femoral fractures result in major blood loss even when closed
* S: point of fracture
* O: Immediate and progressive - Deformity
* Only follows complete fractures - Open wound
* increased likelihood in open fractures
* how much bleeding has occured?
What is tension pneumothorax?
accumulation of air in the thoracic cavity with shifting in the mediastinum
What amount of blood can put a patient in a state of shock? And what are other results of high blood loss?
25% blood loss
heart palpatations, dizziness, LOC
What are the sizes of a pink, yellow, blue, green, grey and orange cannula?
pink: 20g (gauge)
yellow: 24g
blue: 22g
green: 18g
grey: 16g
orange: 14g
the larger the gauge number the smaller the diameter
therefore yellow and blue are typically used for children
Why can someone who has lost a lot of blood still have a normal PCV?
When people lose blood they usually lose plasma over cells therefore replace the plasma with saline first and then take another blood sample to get the actual PCV
What are the golden hours after contamination before the staph aureus from skin that enters a wound multiplies?
6-8 hours
How much fluid is given per cm of wound?
1L/cm of wound
What is debridement?
The process of removing dead and dying tissue from the wound
What is the wound management protocol for a fracture wound exposed to staph aureus?
- Irrigation (pour normal saline or clean water in emergencies, into the wound to flood out contaminants) and
- Debridement
- Analgesic (for both opened and closed)
- Antibiotics (open fractures only)
- Antitetanus prophylaxis (open fractures only)
What are the important 3A’s you must immeduately give to a patient with an open fracture?
Analgesics
Antibiotics
Antitetanus
