Traum - Fractures Flashcards
Pathophysiology (part 1):
of a bone break
bleed blood vessels in bone, periosteum
bleeding, inflamm around bone due soft tissue damage
haematoma/clot forms in medullary canal under periosteum
between ends bone fragments
necrosis end broken bones - torn vessels unable deliver nutrients
inflammatory response develops
Pathophysiology continued (part 2):
What does the haematoma serve as the basis for at fracture sites?
fibrin network - granulation tissue grows
new capillaries extend into tissue
phagocytotic cells, fibroblasts migrate to it
chondroblasts form cartilage
two bones become splinted by procallus/fibrocartilaginous callus (collar)
What does chondroblast do?
(form cartilage)
What do phagocytic cells do?
(removing debris)
What do fibroblasts do?
(laying down new collagen fibres)
How strong are broken bones splinted by procallus (or fibrocartilaginous callus) collar?
not strong enough to bear weight, but constitutes preliminary bridge to repair in the bone
Pathophysiology continued (part 3):
osteoblasts from periosteum and endosteum begin generate new bone - fill gap
gradually fibrocartilaginous callus replaced by bone through extensive osteogenic activity
- forms a bony callus
damaged bone repaired by new bone formation, not scar tissue
subsequent months remodelled by osteoblastic and osteoclastic activity - response mechanical stresses
excessive bone in callus removed
more compact laid down
eventually the bone assumes nowmal appearance
To summarise…
What are the five stages of bone healing?
- Haematoma
- Granulation Tissue
- Procallus(fibrocartilage)
- Bony Calluse
- Remodelling
What is the 1st stage of bone healing?
- Haematoma
What is the 2nd stage of bone healing?
- Granulation Tissue
What is the 3rd stage of bone healing?
- Procallus(fibrocartilage)
What is the 4th stage of bone healing?
- Bony Calluse
What is the 5th stage of bone healing?
- Remodelling
Approximately how long does it take for fractures to heal in Children?
1 month
Approximately how long does it take for fractures to heal in Adults?
2 or more months
Approximately how long does it take for fractures to heal in an Elderly Person?
Many months
Factors affecting the healing of a bone:
- amount of local damage to bone and soft tissue e.g prolonged inflammation, extensive damage periosteum, blood vessels
- more closely approximated ends of bones are, smaller gap - faster filled
- secondary problems e.g. infection at the site
- numerous systemic factors
-immobilisation
Why is it necessary to for bones to be realigned (reduced) in the proper position before healing can occur?
promote healing
prevent deformity
most important to maintain immobilisation to prevent disturbance or damage to developing fragile bridge of tissue
Examples of systemic factors that reduce healing:
Older persons
Circulatory Problems
Anemias
Diabetes mellitus
Nurtitional deficits
Those taking drugs e.g. glucocorticoids
Complications that may affect healing in patients who sustain severe injuries.
8. Fractures IN or NEAR the joint:
Fractures in or near the joint may have long-term residual effects e.g. osteoarthritis, stunted growth in epiphyseal plate
Complications that may affect healing in patients who sustain severe injuries.
7. Non-union and Malunion:
Failure to heal (nonunion)
Healing with deformity(malunion)
may result if the bone is not stabilised with ends closely approximated and aligned
Complications that may affect healing in patients who sustain severe injuries.
3. Ischemia:
develops in a limb following cast tx as oedema increases during first 48 hrs after the trauma and the limb is compressed by the cast
if the peripheral area (e.g. toes, fingers) becomes pale or cold and numb or if the peripheral pulse has decreased or is absent it is likely that the cast has become too tight and is compromising circulation in the limb
the cast must be released to prevent secondary tissue damage
during the later stages of healing, it is also important that the cast does not become to lose and oedema decreased and muscle atrophies because of the newly formed procallus may break down if there is any bone movement
Complications that may affect healing in patients who sustain severe injuries.
4. Compartment Syndrome:
may develop shortly after fracture occurs when there is more extensive inflammation e.g. crush injuries
increased pa of fluid within the fascia, nonelastic covering of the severe pain and ischemia or necrosis of the muscle
pressure effects may be aggravated by a cast
Complications that may affect healing in patients who sustain severe injuries.
5.Fat Emboli:
risk when fatty marrow escapes from the bone marrow into a vein within the first week after injury
more common in pts with fracture of pelvis, long bones, e.g. femur esp when site has not been well immobilised during transportation immediately after injury
What are the risk of Fat Emboli following a fracture?
- travel to lungs = obstruction, extensive inflammation and respiratory distress syndrome may also disseminate into systemic circulation as well
First indications of a Fat Embolus?
- behavioural changes
- confusion
- disorientation associate cerebral emboli in combination with respiratory distress and severe hypoxia
Complications that may affect healing in patients who sustain severe injuries.
6.Nerve Damage:
may occur in a severe trauma or tearing of periosteum
Complications that may affect healing in patients who sustain severe injuries.
1. Muscle Spasms:
may occur as local pain and irritation causes strong muscle contractions at the fracture site
this muscle spasm pulls the bone fragments further out of position causing angulation (deformity), rotation of a bone, or overriding of the bone pieces.
this abnormal movement = more soft tissue damage, bleeding and inflammation
Complications that may affect healing in patients who sustain severe injuries.
2. Infections:
e.g. tetanus/osteomyelitis a threat in persons with compound fractures or when surgical intervention is required
…in such cases precautions inc. wound debridement, application of a widowed cast, tetanus booster shots, prophylactic antimicrobial therapy
Signs and Symptoms of Fractures:
clearly present in some cases e.g. compound fractures, obvious deformity
-swelling
-tenderness at the site
-altered sensation
-inability move a broken limb
-crepitus, grating/creaking/cracking/popping if the bone ends mover over each other
(bone should not be moved to test for this^)
-pain immediately after injury
In what cases does pain sometimes not occur immediately after injury? Why?
compound or multiple fractures
pain is delayed when nerve function at the site is lost temporarily
Where does pain result from in fractures?
direct damage to the nerves by trauma from pressure and irritation due to accumulated blood and inflammatory response
What may severe pain following a fracture result in?
Shock with pallor, diaphoresis, hypotension, tachycardia
Sometimes nausea and vomiting occur
Diagnostic Tests to confirm the presence of Fractures?
X-rays films
Treatment for Fracture:
Immediate splinting and immobilisation - minimise complications
Reduction of fracture - restore bones normal position
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What is Reduction in regards to fractures?
restoring the anatomical alignment of a fracture or dislocation of deformed limb
allows for:
Tamponade of bleeding at the fracture site
Reduction in the traction on the surrounding soft tissues - reducing swelling
Reduction in the traction on the traversing nerves - reducing the risk of neuropraxia
Reduction of pressures on traversing blood vessels - restoring any affected blood supply
How is open reduction accomplished?
surgery, devices such as pins, plates, rods, screws - fix fragments in position; any necrotic or foreign material is removed and the bone ends aligned and closely approximated
How is immobilisation obtained following a fracture?
casts
splints
using traction
What does traction involve?
application of a force or weight pulling on a limb that is opposed by body weight
this force maintains the alignment of the bones, prevents muscle spasms, immobilises the limb
Why are exercises useful following a fracture during the healing period?
limit muscle atrophy in immobilised are
maintain good circulation
minimise joint stiffness or contractures
