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Principles of Fractures

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james penny

on 3 December 2014

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Transcript of Principles of Fractures

Principles of Fractures
Summary
Thank you for your attention!
Ultimate goal of fracture management -
Maximise function / minimise complication
Initial assessment and emergency management
General principles of fracture management
Operative vs Non-operative
General types of fixation
Open Fractures
Complications
Restore the patient to their optimal functional state

Prevent fracture and soft-tissue complications

Get the fracture to heal, and in a position which will produce optimal functional recovery

Rehabilitate the patient as early as possible
In nature
Regeneration vs repair
Three phases of healing by callus
Rapid process, rehabilitation slow, low risk

With operative intervention (open reduction + compression)
Primary bone healing
Slow process, rehabilitation rapid, high risk

With operative intervention (nailing or external fixation)
Healing by callus
Rapid process, rehabilitation rapid, lesser risk
Goals
How Fractures Heal
Management Time Line
Factors Affecting
The energy transfer of the injury
The tissue response
Two bone ends in opposition or compressed
Micro-movement or no movement
BS (scaphoid, talus, femoral and humeral head)
infection
Patient factors
Method of treatment
Surgical skill
Mechanism of injury (traumatic, pathological, stress)
Anatomical site (bone and location in bone)
Configuration and Displacement
Three planes of angulation
Translation
Shortening
Articular involvement/epiphyseal injuries
Fracture involving joint
Dislocation
Ligamentous avulsion
Soft tissue injury
Life saving measures
Reducing a pelvic fracture in haemodynamically unstable patient
Applying pressure to reduce haemorrhage from open fracture

Complication saving
Early and complete diagnosis of the extent of injuries
Diagnosing and treating soft-tissue injuries
A Airway and cervical spine immobilisation

B Breathing

C Circulation (treatment and diagnosis of cause)

D Disability (head injury)

E Exposure (musculo-skeletal injury)
Management of Soft tissues
All severe soft tissue injuries require urgent treatment
Open fractures
Vascular injuries
Nerve injuries
Compartment syndrome


After the treatment of the soft tissue injury the fracture requires rigid fixation

A severe soft-tissue injury will delay fracture healing
Does the fracture require reduction?
Is it displaced /articular?

How accurate a reduction do we need?
alignment without angulation (closed reduction - e.g. wrist)
anatomic (ORIF- e.g. adult forearm )

What is the management plan? weight bearing / moving joints / immobilisation
How to hold the reduction?



What treatment plan to follow?

When can the patient load the injured limb?
When can the patient move the joints?
How long should the fracture be immobilised?
Operative vs Nonoperative

Rehabilitation Rapid Slow
Risk of joint stiffness Low Present
Risk of malunion Low Present
Risk of non-union Present Present
Speed of healing Slow Rapid
Risk of infection Present Low
Cost ? ?
General trend towards operative treatment last 30 yrs
Improved implants and antibiotic prophylaxis
Use of closed and minimally invasive methods
Relative indications:-
Poor functional result with non-anatomical reduction
Loss of position with closed method
Displaced fractures with poor blood supply,
Economic and medical indications
ORIF ( Open Reduction and Internal Fixation)

Closed Reduction and Percutaneous Fixation

Biological Fixation

Intramedullary Nailing

External Fixation
Splintage

Closed reduction and splintage

Traction
Gustilo classification
Type I : low-energy injury,wound less than 1 cm long
Type II: wound greater than 1 cm, moderate amount of soft-tissue damage
Type III: all high-energy/comminuted open #s
A: limited periosteal stripping, bone coverage not a
major problem.
B: extensive stripping of soft tissues and periosteum
from bone, devitalisation or loss of soft tissues,
requires a local flap or free tissue transfer for
closure.
C: a major vascular injury requiring repair for salvage
of the extremity
Clinically
Upper limb Lower limb
Adult 6-8 weeks 12-16 weeks

Child 3-4 weeks 6-8 weeks

Radiologically
Bridging callus formation
Remodelling
'A fracture is a break in the structural continuity of the bone' or is it?
Initial Management
Initial Management
BOA/BAPRAS Guidelines - ATLS/resusitate, inspect wound, remove contamination, photograph, cover wound, antibiotics, tetanus prophylaxis, splint limb, monitor neurovascular status and for compartment syndrome
Classifiy the injury - Gustilo
IV antibiotics - Co-amoxiclav / Gentamicin
Principles
Initial Management
Urgent Wound and Fracture debridement
Stabilization of fracture
Early definitive wound cover
Sequels
Skin - contracture or friable prone to break down
Bone / Implant - infection (S.Aureus, Pseudomonas), non-union
Joints - stiffness
Complications of fractures

Early

Late
Other injuries Chest infection
PE UTI
FES/ARDS Bed sores

Bone
Infection Non-union
Malunion
AVN / OA

Soft-tissues
Plaster sores Tendon rupture
N/V injury Nerve compression
Compartment Volkman’s contracture
Syndrome CRPS
Rehabilitation + treatment of complications
weeks to months
Monitoring of fracture
Days to weeks
Emergency orthopaedic management
Life saving
Complication saving
Life saving measures
Diagnose and treat life threatening injuries
Hold
Move
Speed
Safety
Fracture Quartet
Trauma
Bone Injury
Soft Tissue Injury
Skin
Open fractures, degloving injuries and ischaemic necrosis
Blood vessels
Vasospasm and arterial laceration

Nerves
Neurapraxias, axonotmesis, neurotmesis
Muscles
Crush and compartment syndromes

Ligaments
Joint instability and dislocation
Clinical assessment
History
Co-morbidities
Exposure/systematic examination
“First-aid” reduction
Splintage and analgesia
Radiographs
Two planes including joints above and below area of injury
Fracture patterns and description
Open Fractures
Treating the Fracture
Absolute indications:-
Polytrauma
Displaced intra-articular fractures
Open #’s
#’s with vascular injury or compartment syndrome
Pathological #’s
Non-unions
Local
General
Remember the rule of TWO:   
1.    Two views. At 90 degrees, usually anterior-posterior and lateral.
2.    Two joints. The joints above and below.
3.    Two occasions. Some fractures are not easily visible immediately after trauma.
4.    Two limbs. If required for comparison.

NB: In certain injuries, ‘special’ views are required. These include Scaphoid views, Skyline views for the patello-femoral compartment of the knee and Mortice view at the ankle.
Radiology
How Fractures Happen
Bone is relatively brittle - usually has sufficient strength and resilience withstand stress.

Fractures result from: injury, repetitive stress and pathological weakening
Treat the patient not the fracture!
What about... 'a soft tissue injury that happens to have a broken bone...'
Full transcript