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Orthopaedic Surgery Fractures and dislocations

Tomas Kurakovas MF ll Group 29

Bone fractures: classification ,causes, clinical signs, diagnostics and principles of treatment. Definitions
A fracture is a loss in the normal continuity of bone following the application of a direct or indirect force to that bone. A fracture may involve a part or the entire circumference of the cortex.

In orthopedic medicine, fractures are classified in various ways. Historically they are named after the doctor who first described the fracture conditions. However, there are more systematic classifications in place currently. All fractures can be broadly described as: Closed (simple) fractures are those in which the skin is intact Open (compound) fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection. Other considerations in fracture care are displacement (fracture gap) and angulation. If angulation or displacement is large, reduction (manipulation) of the bone may be required and, in adults, frequently requires surgical care. These injuries may take longer to heal than injuries without displacement or angulation. Compression fractures usually occurs in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma).

Other types of fracture are: Comminuted (more than two fragments) Transverse Oblique Spiral Displaced Angulated Impacted Rotated Distracted

Green stick This occurs when only one cortex of the bone is seen to be fractured on the X-ray, and there is usually minimal deformity. This most commonly occurs in the paediatric age group. Intra-articular Fractures that extend to the articular surface of a joint.

Special fractures.

Pathologic fracture fracture through an abnormal bone. Stress fracture fracture through repeated minor trauma to a normal bone.

Causes of fracture.
Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces or trauma applied to the bone may determine what type of injury that occurs. Some fractures occur without any obvious trauma due to osteoporosis, the loss of calcium in bone (for example a compression fracture of the vertebrae of the back).

Clinical signs and symptoms.

Descriptions of fractures can be confusing. They are based on: Where in the bone the break has occurred How the bone fragments are aligned

Whether any complications exist Whether the skin is intact

The first step in describing a fracture is to decide if it is open or closed. If the skin over the break is disrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries often need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively. Although bone tissue itself contains no nociceptors, bone fracture is very painful for several reasons: Breaking in the continuity of the periosteum, with or without similar discontinuity in endosteum, as both contain multiple nociceptors. Edema of nearby soft tissues caused by bleeding of torn periosteal blood vessels evokes pressure pain. Muscle spasms trying to hold bone fragments in place Damage to adjacent structures such as nerves or vessels, spinal cord and nerve roots (for spine fractures), or cranial contents (for skull fractures) can cause other specific signs and symptoms.

Radiographs All suspected fractures should be X-rayed in two planes (antero-posterior, lateral) Bone scans Suspected fractures, which are not obvious on plain radiographs may be identied by bone scan, which show increased isotope uptake corresponding to the site of the fracture. This may be less apparent in the geriatric group where an osteoblastic response may be less prominent. In the elderly, a delay of one week before bone scanning is usually required to

show a positive scan. Bone scans are useful for detecting femoral neck and pelvic fractures in the elderly and carpal injuries in younger patients. Computed tomography (CT) CT Scans are excellent for delineating cortical and trabecular bone. The plane of the CT should be perpendicular or oblique to the fracture line to detect the fracture. CT is good for demonstrating periosteal new bone formation and may be valuable for diagnosing subtle stress fractures such as minimally displaced femoral neck fractures, pelvic ring fractures, and rib fractures. Magnetic resonance imaging (MRI) Limited MRI scans in the coronal or surgical plane are excellent for demonstrating fractures which are suspected but not readily apparent on plain X-rays. T1 weighted MRIs are able to detect the fracture immediately after injury and T2 weighted images can differentiate soft tissue inammation from intraosseous oedema. MRI scans are excellent for early detection of undisplaced scaphoid and femoral neck fractures.

First aid and management of the whole patient Patients who have suffered violence sufficient to fracture part of their skeleton often have injuries to other systems, some which may be life-threatening. In the management of such multiply injured patients, priority should be given to the ABCs-Airway maintenance, Breathing and Circulation. Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the position it is found, elevation and ice. Immobilization will be very helpful with initial pain control. For injuries of the neck and back, many times, first responders or paramedics may choose to place the injured person on a long board and in a neck collar to protect the spinal cord from potential injury. Once the fracture has been diagnosed, the initial treatment for most limb fractures is a splint. Padded pieces of plaster or fiberglass are placed over the injured limb and wrapped with gauze and an elastic wrap to immobilize the break. The joints above and below the injury are immobilized to prevent movement at the fracture site. This initial splint does not go completely around the limb. After a few days, the splint is removed and replaced by a circumferential cast. Circumferential casting does not occur initially because fractures swell

(edema). This swelling could cause a build up of pressure under the cast, yielding increased pain and the potential for damage to the tissues under the cast. However, if the fracture required reduction (putting the bones back into alignment) there might be a need for circumferential cast to keep the ones in place. Closed fractures The principles of management of a closed fracture include: correction of the deformity (reduction) immobilization of the fracture protection until the fracture has consolidated rehabilitation of the muscles and joints of the affected limb. Closed reduction Under appropriate anesthesia (local, regional, general) the fracture fragments should be manipulated and reduced into normal alignment. In reducing the fracture, combinations of distraction, increasing and then reducing the deformity of the fracture, and holding the reduction with 3 point xation are employed. This technique of reduction is also used with open fractures .

Open reduction Open reduction is indicated when closed manipulation of bone fragments has failed to reduce the fracture into a satisfactory position, if reduction is impossible or if reduction is lost after initial closed reduction. Open reduction may be indicated to stabilize fractures securely to allow safe and effective management of the patients with multiple other bone or soft tissue injuries, or if movement of the adjacent joint is paramount.

Open fractures Open fractures are at risk of developing infections (acute and chronic osteomyelitis). The principles of management include: Cleaning of contaminated tissue. This is usually accomplished by irrigation with copious amounts of sterile or antibiotic loaded irrigation solution. In heavily contaminated wounds, pulsatile irrigation devices are used to agitate the wound to assist in dislodging and diluting out foreign debris.

Debridement of traumatised wound edges and tissue. This step is important to remove necrotic or ischemic tissue which may become foci for infection if colonised by infective organisms. Careful surgical handling of the tissue is mandatory to prevent extension of tissue injury. Stabilisation of fractures. Stability of the fracture is important to protect the surrounding soft tissue from further injury that may occur if the sharp fracture ends were allowed to move. The method of stabilization is important and will depend on the extent of the soft tissue injury. Closure of exposed bone by adequate soft tissue cover. On completion of wound debridement, the soft tissue defect may be closed either by direct suture or tissue grafts. Tissue grafts may be in the form of split skin grafts or tissue aps. The decision regarding closure will depend on the degree of contamination and size of the defect.

Classication of open fractures Open fractures are classied according to the severity of the injury and the modality of injury.

Type 1: Puncture of overlying of skin or mucous membrane by a bony spike from within. Type 2: Laceration less than 1 cm overlying the fracture. Type 3: Laceration greater than 1 cm overlying a fracture. Type 3A: Raising of a soft tissue ap around the fracture. Type 3B: Absolute skin loss around a fracture. Type 3C: Deep and highly contaminated wound such as after a farm injury, gun shot injury and fractures associated with neurovascular injury.

Surgical considerations of open fractures

Type 1 and 2 open fractures which can be thoroughly debrided, cleansed with copious amounts of uid (6 litres) may be able to be xed with internal xation devices. Such injuries are also treated with prophylactic perioperative antibiotics for 48 hours: Kein 1 gm i.v. 6 hourly. Type 3 open fractures are usually xed with external xation devices after thorough debridement, cleansing, and fracture reduction. Frequently soft tissue reconstruction is required to provide closure of the wound: Kein 1 gm i.v. 6 hourly. Type 3C injuries are associated with a poor prognosis and amputation may be required in up to 60% of 3C injuries. A course of antibiotics is usually prescribed and the selection of antibiotics will depend upon the type of contamination introduced into the wound: Vancomycin 1 gm i.v. 12 hourly (adjusted to pre- and postadministration levels) and ceftriaxone 1 gm i.v. 12 hourly.

Fracture immobilization

Splintage Minor fractures such as those effecting the phalanges of the ngers may be treated using small metal or plastic splints.

Plaster of Paris cast Plaster of Paris cast immobilisation is a conventional method of immobilising the fracture following closed reduction. This may be either a completely encircling moulded cast or an incomplete encircling cast (plaster slab).

Traction Some fractures, particularly those involving the lower limb, may be treated temporarily or denitively by the application of traction along the line the limb. Traction encourages normal alignment of the fracture and the increased tension of the surrounding soft tissue helps to provide internal splintage of the fracture.

External xation External xation is the application of transxing pins and bars to create a construct that lies external to the limb and acts to hold the fracture following either open or closed reduction. This method of immobilisation is selected if unstable fractures cannot be held using traditional non-operative techniques. External xation is also indicated when an open and contaminated fracture is at risk of infection and therefore must be held immobilized by

a system which does not introduce into the wound any foreign material such as metal plates and screws.

Internal xation is indicated

when closed reduction has failed when further displacement is anticipated when closed nonoperative immobilisation constitutes a risk to the patient when internal xation allows earlier mobilisation, rehabilitation and earlier return to normal function.Internal xation includes the use of transxing wires, inter fragmentary screws, metal plates, and intramedullary rods.

Fracture Rehabilitation. The goal of rehabilitation of fractures is to restore functional abilities of the individual. Rehabilitation primarily emphasizes restoring full range of motion, strength, proprioception and endurance while maintaining independence in all activities of daily living. Resumption of pre-injury status is the goal with consideration of any residual deficit. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, non-operative).

Complications, outcome Haemorrhage Significant amounts of bleeding may occur into soft tissue depending upon the bone fracture, e.g. closed femoral fractures may loose up to 2 liters of blood into the thigh ,and pelvic fractures up to 4 liters into the pelvic cavity.

Infection Infection is a risk for all open injuries. Intra-articular extension Some fractures extend from bone into the joint. Displacement of articular fragments must be treated by anatomic reduction to reduce the risk of post-traumatic arthritis. Vascular compromise Excessive bleeding or swelling into the soft tissue may induce a compartment syndrome where excessive pressures within a tissue compartment prevents adequate blood flow to that compartment. Unless this is treated expediently necrosis of soft tissue and subsequent scarring may cause loss of limb function or loss of the limb itself. The signs of a compartment syndrome are dominated by pain that is not responsive to analgesia. Increasing pain following limb surgery mandates an examination to exclude a compartment syndrome. Other signs of limb ischemia include pallor, paraesthesia, paralysis, poikylothermia, and pulselessness.

Late complications Delayed union Delayed union occurs when a fracture has not united in a period of time that is at least 25% longer than the expected average time for fracture union at that site.The causes of delayed union include inadequate immobilisation, infection, avascular necrosis of bone, and soft tissue interposition between fracture ends. Delayed union is assessed radiographically. Non-union Non-union is said to have occurred when no evidence of union is seen on sequential X-rays over a six-month period of time.

Mal-union Mal-union occurs when the fracture unites with a loss of anatomical alignment.

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