Post on 31-Dec-2015
description
Principles of Fracture Treatment
What is a (bony) fracture?
Disruption of a bone’s normal structure or “wholeness”
Crack, break, or rupture in a bone
There are many how’s and why’s to bony fracturesTerms used to describe each are related
Definition of Fracture There are 2 types of # in which this is not
so:
1. Pathological fract.
1. Stress fract.
Pathological fracture :
It is one in which a bone is broken through an area weakened by pre-existing disease , & by a degree of force that would have left normal bone intact e.g osteoporosis , O.M. , bone tumours.
Stress fracture :
Bone, like other materials, reacts to repeated loading. On occasion, it becomes fatigued & a crack develops e.g military installations, ballet dancers & athletes.
Diagnosis Clinical picture
Radiography
Clinical Features of Fracture History of trauma Symptoms & signs:1. Pain & tenderness 2. Swelling
3. Deformity 4. Crepitus
5. Loss of function 6. Abnormal move.
7. N.V. injuries
Orthopaedic History A good general orthopaedic history
contains:Onset, Duration, and Location of a problemLimitations and debilitation attributed to the
problemGood surgical history, especially with
regards to orthopaedic surgeries and prior anesthesia
Co-morbid conditions that contribute to the problem or will preclude healing in some manner
Physical Exam Basics Inspect and Palpate everything- start
with normal structures and move to abnormal
Range of motion in all planes Strength Sensation Reflexes Gait Stability
Physical Exam Basics NVI What does this mean?1. Neurologic exam- Always document
the neurologic status. Some fractures are associated with nerve injuries and knowing the status of the nerve is critical
2. Vascular exam- Always check for pulses distal to the fracture sight. Missed vascular injuries can be devastating
Pre-reading Musculoskeletal Radiographs 1: Name, date, old films for
comparison 2: What type of view(s) 3: Identify bone(s) & joint(s)
demonstrated 4: Skeletal maturity
(physes: growth plates) 5: Soft tissue swelling 6: Bones & joints
(fractures & dislocations)
Physical Exam
NEVER trust someone else’s exam. ALWAYS put your hands on the patient and see for yourself
Always trust your exam- you WILL pick up something that someone else has missed at some point
OPEN AND CLOSED FRACTURES
Intro to Reading X-rays
Reading a radiograph is essentially describing the anatomy of a certain structure
In order for it to be universal and understandable for others, clarity and precision are essential
A fracture is described based on the findings of the physical exam and a review of radiographs
Reading X-rays
1. Say what it is- what anatomic structure are you looking at and how many different views are there
2. Regional Location- Diaphysis (rule of 1/3), Metaphysis, Epiphysis including intra and extra-articular
3. Direction of the fracture line- Transverse, Oblique, Spiral
Reading X-rays
5. Condition of the bone- comminution (3 or more parts), Segmental (middle fragment), Butterfly segment, incomplete, avulsion, stress, impacted
6. Deformity-Displacemtent (distal with respect to proximal), angulation (varus, valgus), rotation, shortening (in cm’s), distraction
Fracture Pattern
Transverse Produced by a
distracting or tensile force
Fracture Pattern
Spiral Produced by a
torsional force
Fracture Pattern
Produced by pure bending force
Butterfly
Fracture Pattern
Comminuted Broken into
many pieces- high energy with combined forces
Displacement
Characterized by % of bone contact on either view
Angulation
Distal fragment relative to proximalVarus, Valgus, Anterior, Posterior
Apex of angle formed by fragmentsE.g., Apex Anterior, Apex Medial,
Apex Ulnar
Location
Commonly described in thirds of affected boneie distal third of tibia ie junction of proximal and middle
third of femurIf fractured at two levels describe
as segmental
Location-Diaphysis
Shaft portion of bone
Location-Metaphysis The ends of the bone
(if the fracture goes into a joint it is described as intra- articular)
Now All Together
Transverse fracture of the femur at the middle third- distal third junction with 100% displacement and varus (or apex lateral) angulation
What do you see?
What do you see?
What do you see?
Mnemonic: OLD ACID
O: Open vs. closed L: Location D: Degree (complete vs. incomplete)
A: Articular extension C: Comminution / Pattern I: Intrinsic bone quality D: Displacement, angulation, rotation
O: Open vs. Closed Open fracture
AKA: “Compound fracture” A fracture in which bone
penetrates through skin; “Open to air” Some define this as a
fracture with any open wound or soft tissue laceration near the bony fracture
Closed fracture Fracture with intact overlying
skin
L: Location Which bone? Thirds (long bones)
Proximal, middle, distal third
Anatomic orientation E.g. proximal, distal, medial,
lateral, anterior, posterior
Anatomic landmarks E.g. head, neck, body /
shaft, base, condyle
Segment (long bones) Epiphysis, physis,
metaphysis, diaphysis
Epiphysis
Metaphysis
Diaphysis
)Shaft(
Physis
Articular Surface
D: Degree of Fracture
Complete Complete cortical
circumference involved Fragments are completely
separated
Incomplete Not fractured all the way
through “Only one cortex” involved e.g “Greenstick fracture”
A: Articular Extension / Involvement Intra-articular
fractures “Involves the
articular surface” Dislocation
Loss of joint surface / articular congruity
Fracture-dislocation
C: Comminution / Pattern Transverse (Simple) Oblique (Simple) Spiral (Simple) Linear / longitudinal Segmental Comminuted Compression / impacted
“Buckle / Torus”
Distraction / avulsion
C: Comminution / Pattern Transverse (Simple)
C: Comminution / Pattern Oblique (Simple) Spiral (Simple)
Oblique in 2+ views
C: Comminution / Pattern Linear / longitudinal / split
C: Comminution / Pattern Segmental
Bone broken in 2+ separate places; Fx lines do not connect
C: Comminution / Pattern Comminuted
Broken, splintered, or crushed into >3 pieces
C: Comminution / Pattern
Compression Impacted
(e.g. “Buckle / Torus”)
C: Comminution / Pattern “Buckle / Torus”
C: Comminution / Pattern Distracted Avulsion
I: Intrinsic Bone QualityOsteopenia
–Decr’d density
Normal
I: Intrinsic Bone Quality
Normal Osteopetrosis–Incr’d density
I: Intrinsic Bone Quality Osteopoikilosis
Focal areas of incr’d density
Normal
D: Displacement, Angulation, Rotation
Displacement–Extent to which Fx
fragments are not axially aligned
–Fragments shifted in various directions
relative to each other
–Convention: describe displacement of distal
fragment relative to proximal Oblique tibial shaft Fx b/w
distal & middle thirds; laterally displaced
D: Displacement, Angulation, Rotation
Angulation–Extent to which Fx
fragments are not anatomically aligned
In a angular fashion
–Convention: describe angulation as the
direction the apex is pointing relative to
anatomical long axis of the bone (e.g. apex
medial, apex valgus)
R Tibial shaft Fx b/w prox & middle thirds,
angulated apex lateral (apex varus)
D: Displacement, Angulation, Rotation
Angulation
VarusApex lateral
ValgusApex medial
ParallelNo angulation
D: Displacement, Angulation, Rotation
Rotation–Extent to which Fx
fragments are rotated relative to each other
–Convention: describe which direction the distal
fragment is rotated relative to the proximal
portion of the bone
D: Displacement, Angulation, Rotation
Rotation
Normal PA view of hip–Greater trochanter in
profile
PA view of rotated hip Fx–Greater trochanter
perpendicular to film
Salter-Harris Fractures
Other signs of fractures
Periosteal reaction Callus / Osteosclerosis
Other signs of fractures Fat pad sign / “Sail sign”
Conclusions
Know how to read X-rays
(Patients expect this & we order a lot of them)
Communicate and share with your consultants
(It affects patient outcomes)Pre-readingDescribing fractures
Fracture Classification
Anat. Location
Direction of fract. Line
Wherther the fract. Is linear or comminuted
Condition of overlying S.T.
Mechnism of injury
AO classification
AO Classification
A : Simple fract.
B : Wedge fract.
C : Complex fract.
AO Classification
A= simple fract.
A1 simple fract.Spiral
A2 simple fract.Oblique(≥30)
A3 simple fract.Transverse(<30)
AO Classification
B1 wedge fractSpiral wedge
B2 wedge fractBending wedge
B= wedge fract.
B3 wedge fractfragmented wedge
B= Wedge fract.
B1 wedge fractSpiral wedge
B2 wedge fractBending wedge
B3 wedge fractfragmented wedge
AO Classification
C= complex fract.
C1 complex fract.spiral
C2 complex fract.segmental
C3 complex fract.irregular
Mechanism of Injury Classification
Direct trauma
Indirect Trauma
Direct trauma :
Tapping fractures
Crushing fractures
Penetrating fractures
- High velocity missiles > 2500 f/s
- Low velocity missiles < 2500 f/s
Indirect Trauma : Traction or tension fract.
angulation fract.
Rotational fract.
Compression fract.
Principles of fractures Fracture repair
Fracture repair is a tissue regeneration process rather than a healing process the injured bone is replaced by bone.
The process of repair varies according to: -The type of bone involved. -The amount of movement at the fracture. -The closeness of the fracture surfaces.
Principles of fracturesRate of union
Unfavorable factorsImpairment of blood supplyInfectionExcessive movementPresence of tumorSynovial fluid in intraarticular Fx.Interposition of soft tissueAny form of Nicotine
Definitive fracture treatment
The goal of fracture treatment is to obtain union of the fracture in the most anatomical position compatible with maximal functional return of the extremity.
Conservative
Operative
Principles of Treatment
Treat the Patient, not only the fracture
Restriction of movementPrevention of displacementAlleviation of painPromote soft-tissue healingTry to allow free movement of the
unaffected parts Splint the fracture, not the entire limb
Principles of Treatment
Methods of holding reduction:Sustained tractionCast splintageFunctional bracingInternal fixationExternal fixation
Definitive Fracture Fixation Options
Casts and SplintsAppropriate for many
fractures especially hand and foot fractures
Adults typically will get plaster splints initially transitioned to fiberglass casts as swelling decreases
Kids typically will get fiberglass casts
CLOSED, UNDISPLACEDCLOSED, REDUCIBLE
CONSERVATIVE TREATMENT
2- CAST
Below Knee Above Knee
Complications of cast splintageLiable to appear once the patient has left the
hospital; added risk of delay before the problem is attended to
1. Tight cast
2. Pressure sores
3. Skin abrasion or laceration
4. Loose cast
Functional Bracing
Prevents joint stiffness while still permitting fracture splintage and loading
Most commonly for fractures of the femur or tibia
Since its not very rigid, it is usually applied only when the fracture is beginning to uniteComes out well on all four of the basic
requirements: “hold” “move” “speed” “safe”
Definitive Fracture Fixation Options
TractionUseful in
patients who are too sick for surgery
Useful to maintain alignment until definitive fixation
Traction by gravityEg. Fractures of the humerus
Balanced TractionSkin traction: adhesive strapping kept in place by
bandagesSkeletal traction: stiff wire/pin inserted through
the bone distal to the fracture
Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.
Operative
ORIF (open reduction internal fixat.)
External fixation
Indications of ORIF
- absolute
- relative
Indications of ORIF
- Absolute Indications for ORIF of fractures Unable to obtain an adequate reduction Displaced intra-articular fractures Certain types of displaced epiphyseal fractures Major avulsion fractures where there is loss of
function of a joint or muscle group Non-unions Re- implantations of limbs or extremities
Indications of ORIF
Relative Indications for ORIF of fractures Delayed unions Multiple fractures to assist in care and general
management Unable to maintain a reduction Pathological fractures To assist in nursing care To reduce morbidity due to prolonged
immobilisation For fractures in which closed methods are
known to be ineffective
Indications of ORIF
Questionable Fractures accompanying nerve of vessel
injury Open fractures Cosmetic considerations Economic considerations
Open Operation
Operative reduction under direct vision is indicated:
1. When closed reduction fails2. When there is a large articular
fragment that needs accurate positioning
Open Operation
3. For avulsion fractures in which the fragments are held apart by muscle pull
4. When an operation is needed for associated injuries
5. When a fracture will anyhow need internal fixation to hold it
Types of Internal Fixation
- Pin & wire fixat.
- Screw fixat.
- Plate & screws fixat.
- Intra-medullary fixat.
Plate & screws fixat.
Functional types: Compression plates Neutralization plates Buttress plates Bridge plates LC- DCP Liss plates Locking plates & screws
Definitive Fracture Fixation Options
Open Reduction and Internal fixation with Plates and screwsUsed for many
fractures especially those involving joints
Intra-medullary fixat.
Centro-medullary - Unlocked -Interlocking(static – dynamic – double
locked)
Condylocephalic
Cephalomedullary
Definitive Fracture Fixation Options
Intramedullary NailsTreatment of choice for
most tibia and femur fractures
Used in selected humerus and forearm fractures
Internal Fixation
“holds” securely with precise reduction “movements” can begin at once (no stiffness
and edema) “speed”: patient can leave hospital as soon
as wound is healed, but full weight bearing is unsafe for some time
“safety”= biggest problem! SEPSIS!!!Risk depends on: the patient, the surgeon, the
facilities
Indications for internal fixation
1. Fractures that cannot be reduced except by operation
2. Fractures that are inherently unstable and prone to re-displacement after reduction
3. Fractures that unite poorly and slowly4. Pathological fractures5. Multiple fractures6. Fractures in patients who present severe
nursing difficulties
1. Interfragmentary/Lag Screws:o Fixing small
fragments onto the main bone
2. Kirschner Wireso Hold fragments together where
fracture healing is predictably quick
3. Plates and screwso Metaphyseal
fractures of long bones
o Diaphyseal fractures of the radius and ulna
4. Intramedullary nailso Long boneso Locking screwsresist rotational forces
Joint ReplacementUsed in displaced femoral
neck fractures in geriatric patients
Allows for early ambulationOccasionally used in geriatric
pts with comminuted shoulder or elbow fractures
Definitive Fracture Fixation Options
Complications of internal fixation
Most are due to poor technique, equipment, or operating conditions
Infection○ Iatrogenic infection is now the most common
cause of chronic osteomyelitisNon-union
○ Excessive stripping of the soft tissues○ unnecessary damage to the blood supply in the
course of operative fixation○ rigid fixation with a gap between the fragments
Implant failureRefracture
Definitive Fracture Fixation Options
External FixationUsed primarily in the
treatment of open fractures and pelvis fractures
Also useful as temporary stabilization prior to definitive fixation
External Fixation
Permits adjustment of length and angulation Some allow reduction of the fracture in all 3
planes. Especially applicable to the long bones and the
pelvis. Indications:
1. Fractures of the pelvis, which often cannot be controlled quickly by any other method.
2. Fractures associated with severe soft-tissue damage where the wound can be left open for inspection, dressing, or definitive coverage.
External Fixation
3. Severely comminuted and unstable fractures, which can be held out to length until healing commences.
4. Fractures of the pelvis, which often cannot be controlled quickly by any other method.
5. Fractures associated with nerve or vessel damage.6. Infected fractures, for which internal fixation might not
be suitable.7. Un-united fractures, where dead or sclerotic fragments
can be excised and the remaining ends brought together in the external fixator; sometimes this is combined with elongation in the normal part of the shaft
Complications of external fixation
○ High degree of training and skill! Often used for the most difficult fractures increased likelihood of complications
Damage to soft-tissue structuresOver-distraction
○ No contact between the fragments union delayed/prevented
Pin-track infection
OPEN FRACTURES
Initial Management
At the scene of the accident
In the hospital
Types of Open Fractures Gustilo’s classification of open fractures:
Type 1: low-energy fracture with a small, clean wound and little soft-tissue damage
Type 2: moderate-energy fracture with a clean wound more than 1 cm long, but not much soft-tissue damage and no more than moderate comminution of the fracture.
Type 3: high-energy fracture with extensive damage to skin, soft tissue and neurovascular structures, and contamination of the wound.
Types of Open Fractures
○Type 3 A: the fractured bone can be adequately covered by soft tissue
○Type 3 B: can’t be adequately covered, and there is also periosteal stripping, and severe comminution of the fracture
○Type 3 C: if there is an arterial injury that needs to be repaired, regardless of the amount of other soft-tissue damage
Types of Open Fractures
- The incidence of wound infection- correlates directly with the extent of
soft-tissue damage, <2% in type 1 >10% in type 3
- rises with increasing delay in obtaining soft tissue coverage of the fracture.
Principles of Treatment of Open Fractures
All open fractures assumed to be contaminated Prevent infection!
The essentials:Prompt wound debridementAntibiotic prophylaxisStabilization of the fractureEarly definitive wound coverRepeated examination of the limb because open
fractures can also be associated with compartment syndrome
CONTRAINDICATIONS TO SURGICAL REDUCTION AND STABILIZATION
Situations in which there is a high probability for failure with operative treatment are as follows:
1. Osteoporotic bone that is too fragile to allow stabilization by internal or external fixation.
2. Soft tissues overlying the fracture or planned surgical approach of such poor quality because of scarring, burns,active infection, or dermatitis .
3. Active infection or osteomyelitis.
CONTRAINDICATIONS TO SURGICAL REDUCTION AND STABILIZATION
4. Fracture comminution to a degree that does not allow successful reconstruction. This is most commonly seen in severe intraarticular fractures.
5. General medical conditions that are contraindications to anesthesia are generally contraindications to the surgical treatment of fractures.
6. Undisplaced or stable impacted fractures in acceptable position do not require surgical exposure or reduction.
7. Inadequate equipment, manpower, training, and experience.
Thank you