Extremity trauma

General principles

Dr . Almaghrabi Issam

Damascus Hospital

Definition of fracture Loss of continuity in the substance of bone

Causes

1. Causes of trauma Car accident Work accident Sport accident,…

2. Mechanism of trauma Direct shock

Serious soft tissue lesions

• Indirect shock Flexion Torsion compression

General aspects

A. According to the type of bone: Long bones

• Diaphysis• Epiphysis

* extra-articular

* intra-articular: difficult treatment , ↑↑ complications

Short bones• Scaphoid , Calcaneus, Talus,…

Present diagnostic , therapeutic and prognosis problems

Long bones

Diaphysis

• Epiphysis

extra-articular intra-articular

Short bones

soft tissue lesions

B. According to the age Elderly

Minor trauma ↑↑ morbidity & mortality

e.g. femoral neck fracture Young adult

Violent trauma The risk is local , preserve function

Infant

Violent trauma Minor trauma

Fracture avec décollement épiphysaire de type 1

G

D

Fracture en « motte de beurre » et « bois vert« 

Diagnosis of fractures

A. History1. Trauma itself :

Circumstances of the accident Mechanism of the injury: direct, indirect Time of accident

2. Traumatized patient Functional signs : pain, immobility… Age , past history.

B. Clinical exam (comparative):i. Local examination : signs of the fracture

Inspection : deformation, edema, hematoma, ecchymosis Palpation : tenderness, abnormal mobility.

ii. Regional examination Cutaneous : open fractures, contusion…. Vascular: peripheral pulse, color & temperature Neurological: e.g. humeral fracture (radial n.)

iii. General examination: Clinical: associated lesions Para clinical : ECG, blood analysis, chest X-ray

C. X-ray examination: Technique:

The rule of 2:

2 views , 2 joints , 2 limbs , 2 times Sometimes a special X-rays, e.g. scaphoid.

Results : Site Type Displacement : depending on the distal fragment.

Pitfalls

Elderly patient + unable to weight bear

→ femoral neck fracture Snuff-box pain + normal X-ray

→ suspected scaphoid fracture Dashboard lesions → 2 patellae , femoral shaft , silent hip

dislocation Calcaneus fracture → the other calcaneus + vertebral

column. Ankle sprain → 5th base metatarsal fracture. Epilepsy + shoulder pain → think about post. dislocation. Monteggia – Galeazzi (associated dislocations)

Elderly patient + unable to weight bear

D 21

D 0Snuff-box pain + normal X-ray

Dashboard lesions

Fall from height

Ankle sprain

Epilepsy Post. dislocation

Galeazzi Fracture

Monteggia Fracture

25

Treatment

Primary aims : Bony union without deformity Restoration of function

ER treatment : Alignment of the fracture Temporary splintage Open fractures : sterile bandage , AB , tetanus

Treatment Simple fractures:

±Reduction + casting : After care of patient in plaster swollen fingers – blue – pain → bivalve the cast

Complex fractures : admission Traction : skin – skeletal Open reduction & internal fixation

Indications Failed closed reduction Fractures cannot be held by closed methods (femoral neck) Intra-articular fractures Multiple injuries Techniques Plates , screws , K-wires , nails Interlocking nail , elastic flexible nails

external fixation: open fractures

Casting

Ostéosynthèse du tibia par plaque vissée

Infant

Flexible Titanium Nailing of Tibia

Ostéosynthèse du col fémoral

Bi polar

Evolution Favorable : consolidation within the expected time . Complications:

Immediate : General : choc Loco-regional : skin , vascular , nerves

Secondary : General : DVT , bed sores , infections , fat embolism Loco-regional : secondary displacement , opening ,

necrosis , Volkmann . Late :

Delayed union , nonunion , malunion , arthritis , AVN Functional : pain , stiffness , Sudeck . infection

Volkmann

Non union

Malunion

Sudeck atrophy

Records

Date & time , legible hand writing , employ only common use contractions.

Full record on the day of the admission Write results of X-rays (neg., pos.)

Communications

Telephoning description of the fracture : Age of patient Occupation Type of accident

The rule of 6 A’s

Anatomy (proximal tibia )

Articular

Extra vs Intra

Alignment

A.P. view

Angulation

Lat. view

Apex

Distal fragment

Apposition

75% , 25%

Fracture clinic

What , When 3 A’s (assessment , action , advice) When , What

What , When

What : What we are dealing with (diagnosis)

Recording ↓↓ duplication.

When : Establish the time that has passed since the patient’s

injury

Initial Medical record and X-rays are available.

3 A’s

Assessment : Appropriateness (whether this was the best

treatment )

Action :too tight plaster → split More senior opinion → ↑↑ Outcome.

Advice : It is important to Explain to the patient the nature of his injury,

to keep him Informed of his progress

When , What

When: the date & time of the next appointment .

e.g. ↨ of stitches , ↨ of plaster

What : The purpose of the patients next visit

Save valuable time by avoiding the patient having to wait and seen twice.

QuestionsQuestions???? ????