Musculoskeletal module General Concept of Musculoskeletal InjuryPRINCIPLE OF FRACTURE AND DISLOCATION MANAGEMENT

Musculoskeletal module General Concept of Musculoskeletal InjuryThis presentation

General management for traumaFracture definitionFracture managementTo study a phenomenon of disease without books is to sail un uncharted sea, while to study books without patients is not to go to sea at allSir William Osler

Musculoskeletal Trauma

Musculoskeletal module General Concept of Musculoskeletal InjuryATLS (Advanced Trauma Life Support) : The Beginning ......................................

Musculoskeletal module General Concept of Musculoskeletal InjuryTREAT PATIENT AS A WHOLE HUMAN BEINGNOT PARTIALLY

Initial Managemenet of Trauma PatientMusculoskeletal module General Concept of Musculoskeletal InjuryPrimary SurveySecondary Survey

Concept of Initial AssessmentPrimary SurveyResuscitationReevaluationDetailedSecondary SurveyReevaluationDefinitive CareAdjunctsAdjunctsMusculoskeletal module General Concept of Musculoskeletal Injury

Initial Assessment & Management of Trauma PatientsPrimary survey and resuscitation of vital functions are done simultaneously in a team approachMusculoskeletal module General Concept of Musculoskeletal Injury

Primary SurveyMusculoskeletal module General Concept of Musculoskeletal Injury

Standard PrecautionsCapGownGlovesMaskShoe coversGoggles / face shieldMusculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryAIRWAY PROBLEM ?Airway obstruction

Solid materialFluidPosition

Airway ManagementOrotrachealintubationJaw thrustCricothyroiotomy/tracheostomyMusculoskeletal module General Concept of Musculoskeletal Injury

Primary Survey - BreathingBreathing problemsHemothoraksPneumothoraksFlail chest +lung contusionMusculoskeletal module General Concept of Musculoskeletal Injury

Primary SurveyAssess and ensure adequate oxygenation and ventilationPitfalls ?Airway vs ventilation problem ?Iatrogenic pneumothorax or tension pneumothorax

Primary Survey - BreathingNeedle thoracocentesisChest tubeinsertionMusculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryCIRCULATIONHypovolemic shock

PULSE BLOOD PRESURE DISORIENTATIONCLAMMY SKIN

Primary SurveyControl hemorrhageRestore volumeReassess parametersCirculatory managementMusculoskeletal module General Concept of Musculoskeletal Injury

Primary Survey - CirculationControl bleedingDirect pressureSurgical procedureVascular access Peripheral veinsCentral veinVenous cutdownIntra osseus infusionMusculoskeletal module General Concept of Musculoskeletal Injury

Primary Survey CirculationVascular AccessPeripheral vein infusionVenouscutdownIntraoseusinfusionMusculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryMUSCULOSKELETAL PROBLEM IN PRIMARY SURVEYPELVIC FRACTUREFEMORAL FRACTUREMULTIPLE FRACTURE

What is the secondary survey ?The complete history and physical examinationAnteriorMusculoskeletal module General Concept of Musculoskeletal Injury

When do I start it ?AfterPrimary survey is completedABCDEs are reassessedVital functions are returning to normalMusculoskeletal module General Concept of Musculoskeletal Injury

What are the components ?History : AMPLEPhysical exam : head to toeTubes and fingers in every orificesComplete neurologic examSpecial diagnostic testsReevaluationMusculoskeletal module General Concept of Musculoskeletal Injury

Secondary Survey - HistoryA llergyM edicationP ast Medical HistoryL ast MealE vent at InjuryMusculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryFRACTUREStructural break in its continuity, whether its a bone, an epiphyseal plate or a cartilaginous joint surface

Robert Bruce Salter

Result of single or multiple mechanical overload on bone Overload results in discontinuity of bone architectureHappens in milisecondsAlways has soft tissue damagesWHAT IS FRACTURE ?

Open vs closedComplete vs incompleteStable vs unstableLife or limb threateningStand alone or part of poly traumaFRACTURES CAN BE

Life threatening injuries- Blood loss- Fat embolism- Crush syndrome

Limb threatening injuriesOpen fractures & joint injuriesVascular injuriesCompartment syndromeNeurologic injuries

Initial ManagementPrimary Survey A irway + C-spine controlB reathingC irculation + bleeding controlD isabilityE xposureSecondary survey

Initial ManagementImmobilization of fractureBleeding controlPain reliefAvoid further complicationSplint early, avoid delay in resuscitation

Fracture treatmentsR ecognition g DiagnoseR eduction g Put it thereR etention g Keep it there Await fx healing R ehabilitation4 R

RecognitionBony injuriesClinical findingsRadiological findingsSoft tissue injuries

Clinical Signs of FractureLookFeelMove

Adequate X-Rays2 views (tangential to each other)2 joints (above and below the fracture)2 bones (for comparison with other side)2 occasions (for comparison, to assess progress)Fullfill the rule of 2s

Diagnosing soft tissue injuries

TissuesInjuriesSkinsOpen fx, degloving, ischaemic necrosisMuscles & tendoncrush, compartment syndromeBlood vesselvasospasm, arterial lacerationNervesneuropraxia, axonotmesis, neurotmesisLigamentsjoint instability, dislocation

Soft tissue injuriesSkin & muscle injuryLigament injuryNerve injuryVascular injury

How to describe a fractureWhich bone ?HumerusRadius / ulnaFemurTibia etc

How to describe a fractureWhich bone segment ?Proximal / metaphysisMiddle / diaphysisDistal / metaphysisMalleolar segment for distal tibia or fibula

How to describe a fractureIs the fracture diaphyseal or metaphyseal ?If metaphyseal part is involved, does the fracture involve the joint ?Which fracture type ?Extra articularIntra articular

How to describe a fractureTilt / angulationShiftRotationDisplacement ?

How to describe a fractureDisplacement ?ShorteningAngulationShiftRotation

How to describe a fractureDisplacementTilt / angulationShiftRotationangulationshorteningrotation

How to describe a fractureShape

Musculoskeletal module General Concept of Musculoskeletal Injury Tibial fracture Diaphyseal fracture Comminutive type fracture Medial/varus displacement

Musculoskeletal module General Concept of Musculoskeletal InjuryDistal radius fractureMetaphyseal partComminutive fractureIntra articular fracture

ReductionManipulation (closed reduction) + internal/external fixationTractionOpen Reduction + internal/external fixationAnatomical reduction vs functional reduction

ReductionAnatomical reduction : intra articular fractureFunctional reduction Some fractures do not need to be reducedOpen vs minimal invasive method

Non surgicalSlingCast (POP or fibrecast) / braceTractionSurgical K-wirePlate and screwIntramedullary deviceExternal fixatorProsthetic replacementRetention

Fracture treatment - RetentionCastingSlingTractionK-wireDHSIM nailJoint replacementExternal FixatorInternal Fixation

REHABILITATIONRestoring the patient as close to pre-injury functional level as possibleMay not be possible in certain conditions : severe fractures or elderly patientsApproach needs to be : pragmatic with realistic target, and multidisciplinary

RehabilitationRehabilitation : should start as early as possiblePrevent fracture disease : stiffness, oedema, muscle atrophyPassive and active motion (Range of Motion)Muscle strengtheningEnduranceNWB, PWB, FWBknee CPM elbow CPM CPM = Continuous Passive Movement

Musculoskeletal module General Concept of Musculoskeletal InjuryDEFORMITY OF THE BONEDiscontinuity ; angulation, rotationBony outgrowthAbnormal length

Musculoskeletal module General Concept of Musculoskeletal InjurySTAGES OF FRACTURE HEALING

Musculoskeletal module General Concept of Musculoskeletal Injury

*Musculoskeletal module General Concept of Musculoskeletal Injury

Conditions that interfere with fracture healingPoor blood supply to the fractured area could lead to avascular necrosisPoor immobilization of fracture site may cause misalignment or deformityInfection, more common in open fractures

Musculoskeletal module General Concept of Musculoskeletal InjuryDISLOCATIONSEPARATION OF THE JOINT

Dislocation / SubluxationDislocation : bones in a joint become displaced or misalignedSubluxation : partial dislocationEmergency condition

Dislocation / SubluxationDislocationSubluxation

WHAT HAPPENED IF DISLOCATION OCCURED ?Vascular injurySoft tissue entrapmentNerve injuryAssociated with fractureLigament injury

Dislocation & SubluxationTreatmentInitial treatmentImobilization in position as foundDefinitive treatmentClosed reduction, usually with GAOpen reduction, if closed red fail

Musculoskeletal module General Concept of Musculoskeletal InjuryOPEN FRACTUREBONE EXPOSED TO OUTER ENVIRONMENT

Musculoskeletal module General Concept of Musculoskeletal InjuryGUSTILLO & ANDERSON ( 1985 )GRADE 1

Wound < 1 cmUsually in-out woundSimple fractureMild-modreate contaminationGrading of open fractures

Musculoskeletal module General Concept of Musculoskeletal InjuryGRADE 2

Wound > 1 cmPeriosteal sleeve exposedNo soft tissue avulsionShort oblique fractureModerate contaminationGrading of open fractures

Musculoskeletal module General Concept of Musculoskeletal InjuryGRADE 3 A

Periosteal strippedSoft tissue avulsion but still adequate coverageCommunitive fractureModerate high contaminatedGrading of open fractures

Musculoskeletal module General Concept of Musculoskeletal InjuryGRADE 3 B

Periosteal stripped and no adequate soft tissue coverage that will require surgical coverageComminutive fractureHigh contaminatedGrading of open fractures

Musculoskeletal module General Concept of Musculoskeletal InjuryGRADE 3 C

Open fracture with major artery disruption Grading of open fractures

Musculoskeletal module General Concept of Musculoskeletal InjuryHOW TO TREAT ??Clean the woundAntibiotic based on cultureFixed the fractureAdequate fracture coverage

Musculoskeletal module General Concept of Musculoskeletal InjuryCOMPARTMENT SYNDROMEDisruption of distal extremity perfussion cause by increasing intracompatment pressure

Compartment SyndromeAn increased pressure within enclosed osteofascial space that reduces capillary perfussion below level necessary for tissue viability; the underlying mechanism is :increased volume within spacedecreased space for contentscombination of bothDefinition

Osteofascial Compartment

Compartment Syndrome DiagnosisHistoryClinical examination : 5 PsCompartment pressure measurementLaboratory : CPK, urine myoglobin

Musculoskeletal module General Concept of Musculoskeletal InjuryPain ( passive strech ) ParestesiaPallorPuffinessPlegiPulselessCompartment Syndrome

Musculoskeletal module General Concept of Musculoskeletal InjuryCompartment SyndromePressure measurementWhiteside technique

Musculoskeletal module General Concept of Musculoskeletal InjuryViscious cycle

Musculoskeletal module General Concept of Musculoskeletal InjuryTREATMENTRelease all cast or devices tightened the extremityElevation the extremityRelease the pressure by fasciotomyCUT THE VISCIOUS CYCLE

*Musculoskeletal module General Concept of Musculoskeletal InjuryFasciotomy

Musculoskeletal module General Concept of Musculoskeletal InjuryFRACTURE OF UPPER EXTREMITY

Musculoskeletal module General Concept of Musculoskeletal InjuryColles fractureBCASigns of Colles fracture

Musculoskeletal module General Concept of Musculoskeletal InjuryABC

Musculoskeletal module General Concept of Musculoskeletal InjuryDefined as :

Fracture through the flare out disal metaphyses of radius, with dorsally displaced of distal fragment followed with styloid ulna fractureAbraham Colles ( 1773 1843 )

Musculoskeletal module General Concept of Musculoskeletal InjuryTreatment

Musculoskeletal module General Concept of Musculoskeletal InjurySmith FractureDefined as reverse colles with distal fragmen of distal radius metaphysis displaced anteriorly

Musculoskeletal module General Concept of Musculoskeletal InjuryFOREARM FRACTUREFracture of diaphysis of radius and ulna

Musculoskeletal module General Concept of Musculoskeletal InjuryTreatment

Musculoskeletal module General Concept of Musculoskeletal InjuryGALEAZZI FRACTUREFRACTUREDISLOCATION

Musculoskeletal module General Concept of Musculoskeletal InjuryDefined as :

Fracture of one third radius diaphysis associated with dislocation of distal radioulnar joint

Musculoskeletal module General Concept of Musculoskeletal InjuryTreatmentIndication for open reduction and internal fixation cause by high rate of non union

Musculoskeletal module General Concept of Musculoskeletal InjuryMonteggia fractureDISLOCATIONFRACTURE

Musculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryDefined as

Fracture of one third proximal ulna diaphysis associated with proximal radioulna dislocation

Musculoskeletal module General Concept of Musculoskeletal InjuryTREATMENTOPEN REDUCTION AND INTERNAL FIXATION INDICATED FOR MONTEGGIA FRACTURE

Musculoskeletal module General Concept of Musculoskeletal Injury?

Musculoskeletal module General Concept of Musculoskeletal InjuryDISLOCATION OF THE ELBOW EMERGENCY BEWARE OF NERVE INJURY BEWARE OF VASCULAR INJURY

Musculoskeletal module General Concept of Musculoskeletal InjuryCHECK PULSATION OF RADIAL AND ULNAR ARTERY !!!IN CASE OF NO PULSATION :

ONE ATTEMP FOR REALIGNMENT IMMOBILIZED REFER AS SOON AS POSSIBLE

Musculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryHUMERAL FRACTUREFACT IN HUMERAL FRACTURE

90 % CASE HEALED BY NON OPERATIVE TREATMENTMOST COMMON SITE FOR METASTASES AND PRODUCED PATHOLOGIC FRACTUREMOST COMMON FRACTURE ASSOCIATED WITH NERVE INJURY

Musculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjurySHOULDER DISLOCATIONShoulder joint depend its stability on the joint capsule and surrounding muscleLittle bony stabilityMost sequela after injury is instabilityMost common is anterior dislocation, and rarely psoterior dislocation

Musculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryTREATMENT

Musculoskeletal module General Concept of Musculoskeletal InjuryFRACTURE OF LOWER EXTREMITY

Musculoskeletal module General Concept of Musculoskeletal InjuryHIP DISLOCATION

Musculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryTYPE OF HIP DISLOCATION RELATED OF POSITION OF FEMORAL HEAD TO THE ACETABULUMANTERIOR DISLOCATIONPOSTERIOR DISLOCATIONCENTRAL DISLOCATION

Musculoskeletal module General Concept of Musculoskeletal InjuryFEMORAL FRACTUREProximal part a. Intertrachanter b. Subtrcochanter

Diaphyseal fracture a. 1/3 proximal b. 1/3 middle c. 1/3 distal

Distal part a. Condylar b. Supracondylar c. Intercondylar

Femoral fracture treatmentSkin tractionElastic nailIM nailLockingplateHemispica

Musculoskeletal module General Concept of Musculoskeletal InjuryKnee dislocation

Musculoskeletal module General Concept of Musculoskeletal InjuryTIBIA PLATEAU FRACTURE

Musculoskeletal module General Concept of Musculoskeletal Injury

Musculoskeletal module General Concept of Musculoskeletal InjuryANKLE FRACTURE

Musculoskeletal module General Concept of Musculoskeletal InjuryPEDIATRIC FRACTURENOT A SMALL ADULT

Musculoskeletal module General Concept of Musculoskeletal InjuryWHAT MAKE DIFFERENT ?? Fractures more common Stronger and more active periosteum More rapid fracture healing Specials problem of diagnosisSpontaneous correction of certain residual deformation Differences in complication Different emphasis on methods of treatment Torn ligaments and dislocation less common Less tolerance of major blood loss

Musculoskeletal module General Concept of Musculoskeletal InjuryIf you do not know what you do not know, its the end of learning

*Musculoskeletal module General Concept of Musculoskeletal Injury?

Thank YouDankeArigatoGraciasMaturnuwun