Approach to Fracture Bone

8/6/2019 Approach to Fracture Bone

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APPROACH TO FRACTURE BONEAPPROACH TO FRACTURE BONE

ININ

EMERGENCY DEPARTMENTEMERGENCY DEPARTMENT

DR. RASHDAN RAHMATDR. RASHDAN RAHMAT

HUSMHUSM

20062006


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OUTLINESOUTLINES

IntroductionIntroduction

Types of fractureTypes of fracture

Management of fractureManagement of fracture-- in generalin general

-- specific types of fracturespecific types of fracture

ComplicationsComplications


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INTRODUCTIONINTRODUCTION

- Bone has its own mechanism to ward off the unnatural

forces and keep itself intact.

- but, if the force is :

-too large and occurs suddenly(as in MVA, fall etc), OR

- chronic and repetitive (eg prolonged standing/used);

OR

- when the natural resistance of the bone is eroded by

a disease process (eg tumor, infection etc),

that a bone succumbs to the insult and breaks.

- When it breaks, it is bound to injure the surrounding soft

tissue like muscles, ligaments etc.


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Severity ranges from trivial sprains to lifeSeverity ranges from trivial sprains to life-- or limbor limb--

threatening trauma.threatening trauma.

Often acute trauma is the cause of the presentation.Often acute trauma is the cause of the presentation.

Pain and decreased ROMPain and decreased ROMare the main symptomsare the main symptoms

Life threatening injuriesLife threatening injuries Limb threatening injuriesLimb threatening injuries

multiple trauma patientmultiple trauma patient

severe crush injurysevere crush injury

amputationamputation

pelvic injurypelvic injury

severe vascular injurysevere vascular injury

compound fracturescompound fractures

compartment syndromecompartment syndrome

vascular injuryvascular injury

dislocation of major jointsdislocation of major joints

nerve injurynerve injury


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FRACTURE :

FRACTURE :

a break in the surface of a bone, either across its cortexa break in the surface of a bone, either across its cortex

or through its articular surface.or through its articular surface.

Ds in fracture :Ds in fracture : Deformity is seen often in displaced fracturesDeformity is seen often in displaced fractures

Displacement could be anterior, posterior, medial orDisplacement could be anterior, posterior, medial or

laterallateral

Distal fragment is the reference point to suggest the typeDistal fragment is the reference point to suggest the typeof displacementof displacement


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TYPES OFFRACTURE :TYPES OFFRACTURE :

1.1. Simple / closed vs Compound / openSimple / closed vs Compound / open

2.2. Based on the patterns of fractureBased on the patterns of fracture


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1. Simple / Closed Fracture :1. Simple / Closed Fracture :

The bone breaks within its soft tissue envelope and notThe bone breaks within its soft tissue envelope and not

communicate to the exterior.communicate to the exterior.


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2. Compound / Open Fracture :2. Compound / Open Fracture :

The bone breaks / rip through its soft tissues or the softThe bone breaks / rip through its soft tissues or the soft

tissue itself may be damaged by the external forces,tissue itself may be damaged by the external forces,

exposing the bone to the external atmosphereexposing the bone to the external atmosphere

(communicate to the exterior)(communicate to the exterior)

Eg. open elbow fracture


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II. BASED ON THEFRACTUREPATTERNS :II. BASED ON THEFRACTUREPATTERNS :

1. Linear fracture :1. Linear fracture : Transverse, oblique orTransverse, oblique or

spiralspiral

-- # angle < 30 with the# angle < 30 with the

horizontal line :horizontal line : transversetransverse-- angleangle >> 30 :30 : obliqueoblique

2. Comminuted fracture :2. Comminuted fracture :

The fracture fragments >2 inThe fracture fragments >2 innumbernumber

3. Segmental fracture :3. Segmental fracture :

Breaks into segmentsBreaks into segments


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OTHER TYPES OFFRACTURES :OTHERTYPES OFFRACTURES :

a. Green stick fracture :a. Green stick fracture :Seen in childrenSeen in children

The bone is elastic, usually bends due to buckling orThe bone is elastic, usually bends due to buckling orbreaking of one cortex when a force is applied.breaking of one cortex when a force is applied.

b. Stress / fatigue fracture :b. Stress / fatigue fracture :As a result of being subject to uncustomary repetitiveAs a result of being subject to uncustomary repetitiveforces before the bone and its supporting tissues haveforces before the bone and its supporting tissues havehad adequate time to accommodate to such forces.had adequate time to accommodate to such forces.

Eg.Eg. March fractureMarch fracture in soldiersin soldiers

c. Pathological fracture :c. Pathological fracture :Occurs in diseased bone, from a relatively minor traumaOccurs in diseased bone, from a relatively minor trauma


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SALTERSALTER -- HARRISFRACTUREHARRISFRACTURE

Type IType I fracture is when there isfracture is when there is

a fracture across the physisa fracture across the physiswith no metaphysial orwith no metaphysial or

epiphysial injuryepiphysial injury

Type II fracture is when there is

a fracture across the physiswhich extends into the

metaphysis

# involving the physis, the cartilaginous epiphyseal plate near the ends# involving the physis, the cartilaginous epiphyseal plate near the endsof the long bones ofof the long bones ofgrowing childrengrowing children

The damage may destroy part or all of its ability to produce new boneThe damage may destroy part or all of its ability to produce new bone

substance, resulting in aborted or deformed growth of the bone thereafter.substance, resulting in aborted or deformed growth of the bone thereafter.


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SALTERSALTER -- HARRISFRACTUREHARRISFRACTURE

Type IIIType III fracture isfracture is

when there is awhen there is afracture across thefracture across thephysis which extendsphysis which extendsinto the epiphysisinto the epiphysis

Type IVType IV fracture isfracture iswhen there is awhen there is afracture throughfracture throughmetaphysis, physis,metaphysis, physis,and epiphysisand epiphysis

Type VType V fracture isfracture is

when there is awhen there is a

crush injury to thecrush injury to the

physisphysis


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MANAGEMENT :MANAGEMENT :

GOAL :

- to restore the anatomy back to its normal or as near to

normal as possible.


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MANAGEMENT IN ED :MANAGEMENT IN ED :

Primary survey :Primary survey :

Identify the life threatening injuries

ABCDE must be observed in all injuries be it serious ortrivial

E exposure :- completely undress the patient for total

assessment of the limbs

Secondary survey :

Give greater attention to the extremities

Look for perfusion, alignment, function of the involvedlimbs / extremities


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MANAGEMENT IN EDMANAGEMENT IN ED --Clinical features :Clinical features :

oo Pain, tenderness on palpationPain, tenderness on palpation

oo Loss of functionLoss of function unable to moveunable to move

oo DeformityDeformity angulation, shortening, rotatedangulation, shortening, rotated

oo SwellingSwelling

oo Abnormal postureAbnormal posture

oo CrepitusCrepitus gritty feeling at fracture sitegritty feeling at fracture site

* exam of the* exam of the pulsepulse andand neurological statusneurological status isismandatory in all fracturesmandatory in all fractures


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MANAGEMENT IN EDMANAGEMENT IN ED --Closed fracturesClosed fractures ::

3 aspects of exam. :3 aspects of exam. :

1.1. LOOKLOOK for deformity, wounds, swelling, colour andfor deformity, wounds, swelling, colour and

general appearance of the limbsgeneral appearance of the limbs

2.2. FEELFEEL for the distal pulses and detect loss offor the distal pulses and detect loss of

sensationsensation

3.3. MOVEMOVE the joints above and below the fracturethe joints above and below the fracture

Splinting :Splinting :

Prevents further STIPrevents further STI

Reduces painReduces pain

Facilitates transportationFacilitates transportation

Reduction :Reduction :

reduces compromise of skin,

nerve and vascular structures

facilitates splinting


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MANAGEMENT IN EDMANAGEMENT IN ED Open / Compound #Open / Compound #::

Aims of treatment :Aims of treatment :To convert a contaminated wound into a clean woundTo convert a contaminated wound into a clean woundand thus help to convert an open fracture into a closedand thus help to convert an open fracture into a closedoneone

To establish a union in a good positionTo establish a union in a good position

To prevent pyogenic and clostridial infectionsTo prevent pyogenic and clostridial infections

Methods :Methods :

1.1. Careful and detailed examinationCareful and detailed examination

2.2. Removal of any gross contamination (by thoroughRemoval of any gross contamination (by thoroughirrigation), application of sterile dressing and splintingirrigation), application of sterile dressing and splintingof fractureof fracture

3.3. Tetanus prophylaxisTetanus prophylaxis

4.4. Admin. of IV antibioticsAdmin. of IV antibiotics


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For muscle, non viable tissue has to be removedFor muscle, non viable tissue has to be removed 5Cs :5Cs :

** ImmobilizationImmobilization key in the Rx of MSK traumakey in the Rx of MSK trauma

Prevent furtherSTIPrevent furtherSTIRelieves painRelieves pain

Possibly decreases the incidence of fat embolism andPossibly decreases the incidence of fat embolism and

shockshock

Facilitates transportationFacilitates transportation

FeaturesFeatures ViableViable Non viableNon viable

ColourColour

ConsistencyConsistency

Capacity to bleedCapacity to bleed

CirculationCirculation

ContractilityContractility

PinkPink

FirmFirm

PreservedPreserved

PresentPresent

PresentPresent

PalePale

FlabbyFlabby

LostLost

AbsentAbsent

AbsentAbsent


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PELVICFRACTUREPELVICFRACTURE


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PelvicFracturePelvicFracture

Least common fractureLeast common fracture (3%)(3%)

Most are result of MVA (60%)Most are result of MVA (60%)

Commonly associated with other injuriesCommonly associated with other injuries

-- 50% have intraabd. Injuries50% have intraabd. Injuries

-- 15% have urethral injuries15% have urethral injuries

-- 10% have bladder injuries10% have bladder injuries

Pelvis contains many important structures :Pelvis contains many important structures :

-- Iliac vesselsIliac vessels

-- dense presacral venous plexusdense presacral venous plexus

-- urogenital organsurogenital organsMajor ligaments :

- sacroiliac, sacrospinatus, sacrotuberous

Patients can sustain large volume blood lossPatients can sustain large volume blood loss

(up to 4 L)(up to 4 L)


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ANATOMY OFPELVIS :ANATOMY OFPELVIS :


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PelvicFracturePelvicFracture --Clinical Evaluation :Clinical Evaluation :

Any patient assessment begins with the ABCDEsAny patient assessment begins with the ABCDEs

Complete neurologic and vascular examComplete neurologic and vascular exam

Have high suspicion of intraHave high suspicion of intra--abdominal injuriesabdominal injuries (50%)(50%)

Physical exam :Physical exam : Ecchymosis or contusion around hips, perineumEcchymosis or contusion around hips, perineum

Pelvic instability with stressingPelvic instability with stressing

Suspect if signs of urologic findings : blood atSuspect if signs of urologic findings : blood at

urethral meatus, highurethral meatus, high--riding prostateriding prostate High force mechanisms also associated (MVA,High force mechanisms also associated (MVA,

femur #)femur #)


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PelvicFracturePelvicFracture Management :Management :

1. Control of bleeding vessels1. Control of bleeding vessels

Hemorrhage / hypovolemic shockHemorrhage / hypovolemic shock -- the most significantthe most significantcomplication of pelvic #complication of pelvic #

-- require blood transfusion (maintain HCT > 20%)require blood transfusion (maintain HCT > 20%)

2. Pelvis stabilization :2. Pelvis stabilization :

External fixation techniquesExternal fixation techniques pelvic clamp, hammockpelvic clamp, hammockapplicationapplication

These can help in controlling ongoing bleedingThese can help in controlling ongoing bleeding

33. Surgical management of the broken bone can proceed. Surgical management of the broken bone can proceedLATER after lifeLATER after life--threatening conditions are controlled.threatening conditions are controlled.


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Long Bone Fractures :Long Bone Fractures :

Fractures of the femur, humerus, tibia / fibulaFractures of the femur, humerus, tibia / fibula

Blunt and penetrating traumaBlunt and penetrating trauma

RequiresRequires high energyhigh energy to break bone, thereforeto break bone, therefore

look for other injuries.look for other injuries.# cause localized bleeding and this can be# cause localized bleeding and this can besubstantial resulting in hypovolemic shock.substantial resulting in hypovolemic shock.

Humerus # : 0.5Humerus # : 0.5 1.5 L1.5 L

Unilateral tibia / fibula # : 0.5Unilateral tibia / fibula # : 0.5 1.5 L1.5 L

Femur # : 1.0Femur # : 1.0 2.5 L2.5 L


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Long Bone FracturesLong Bone Fractures Management :Management :

ABCDEsABCDEs

Neurovascular exam (vascular +/Neurovascular exam (vascular +/-- nerve injury)nerve injury)

Splint involved extremitySplint involved extremity

Reduction decreases pain, bleedingReduction decreases pain, bleeding

Orthopedic consultation for definitiveOrthopedic consultation for definitivemanagementmanagement

Complications :Complications :

FatFat--emboli syndromeemboli syndrome

Blood lossBlood loss


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COMPLICATIONSCOMPLICATIONS

ACUTEACUTE CHRONICCHRONIC COMP. PECULIARTOCOMP. PECULIARTO

OPEN FRACTURESOPEN FRACTURES

1. SHOCK(hypovolemic or1. SHOCK(hypovolemic or

neurogenic)neurogenic)

2. ARDS2. ARDS

3.3. THROMBOEMBOLISMTHROMBOEMBOLISM

4.4. NEUROVASCULARNEUROVASCULAR

INJURYINJURY

radial N palsy in # shaftradial N palsy in # shaft

humerushumerus

Sciatic N palsy in post. disl.Sciatic N palsy in post. disl.of hipof hip

brachial A injury inbrachial A injury in

supracondylar #supracondylar #

5.5. COMPARTMENTALCOMPARTMENTAL

SYNDROMESSYNDROMES

DELAYEDUNIONDELAYEDUNION

NONUNIONNONUNION

MALUNIONMALUNION

SHORTENINGSHORTENING

GROWTHGROWTH

DISTURBANCESDISTURBANCES

AVASCULARAVASCULAR

NECROSISNECROSIS

JOINTSTIFFNESSJOINTSTIFFNESS

POSTTRAUMATICPOSTTRAUMATIC

ARTHRITISARTHRITIS

MYOSSITISMYOSSITIS

OSSIFICANSOSSIFICANS

INFECTIONSINFECTIONS

CHRONICCHRONIC

OSTEOMYELITISOSTEOMYELITIS

GASGANGRENEGASGANGRENE

TETANUSTETANUS


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Fracture Complications :Fracture Complications :

1. Vascular Injuries1. Vascular Injuries Most commonly occur inMost commonly occur in open #, #open #, #--dislocationsdislocations, or, or

widely displaced #widely displaced # andandat sites where the vessels lieat sites where the vessels liein close proximity to the bonein close proximity to the bone ororat sites where theat sites where thevessels are held in a relatively fixed position.vessels are held in a relatively fixed position.

Classic signs:Classic signs:The 5 Ps:The 5 Ps:

PainPain

PallorPallor

Pulselessness (or diminished pulse)Pulselessness (or diminished pulse) ParesthesiaParesthesia

ParalysisParalysis..

Location of # and MOI dictate need to assess forLocation of # and MOI dictate need to assess for

potential vascular injury in asymptomatic patient.potential vascular injury in asymptomatic patient.


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2. Nerve Injuries2. Nerve Injuries

OccurOccurmore frequentlymore frequently than vascular injuries inthan vascular injuries in

assoc. with #.assoc. with #.

Can occur due to blunt trauma, along path ofCan occur due to blunt trauma, along path ofpenetrating trauma, or be caused by the # fragmentspenetrating trauma, or be caused by the # fragments

themselves.themselves.

Nerves are at increased risk of injury when they are :Nerves are at increased risk of injury when they are :

superficial to the skin,superficial to the skin, lie close to the bone, orlie close to the bone, or

over a joint, making them susceptible to stretchover a joint, making them susceptible to stretch

injury.injury.


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3. Fat Emboli Syndrome (FES)3. Fat Emboli Syndrome (FES)

Most common form of nonMost common form of non--thrombotic embolism.thrombotic embolism.

Single or multiple long bone fractures in young or pelvic / hip fracturesSingle or multiple long bone fractures in young or pelvic / hip fracturesin elderly predispose to FES.in elderly predispose to FES.

20%20% of patients with pelvic or long bone fractures have detectable fatof patients with pelvic or long bone fractures have detectable fatdroplets in their blood. Vast majority remain asymptomatic.droplets in their blood. Vast majority remain asymptomatic.

HasHas characteristic clinical courses :

1. Fracture sustained.1. Fracture sustained.

2. Other than fracture2. Other than fracture--associated pain, patient is asymptomatic forassociated pain, patient is asymptomatic for1

21

2--36 hours.36 hours.3. Sudden onset of life3. Sudden onset of life--threatening syndrome characterized by rapidthreatening syndrome characterized by rapid

cardiopulmonary and neurologic deterioration, agitation,cardiopulmonary and neurologic deterioration, agitation,hallucinations, delirium, coma, hypoxia, dyspnea, tachypnea, andhallucinations, delirium, coma, hypoxia, dyspnea, tachypnea, andtachycardia leading totachycardia leading to DIVC and ARDS.


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4. Compartment Syndrome4. Compartment Syndrome

Occurs whenOccurs when pressurepressure within soft tissues in awithin soft tissues in a fixed bodyfixed bodycompartmentcompartment increasesincreases to level that exceedsto level that exceeds venousvenouspressure, compromising venous blood flow, and limitingpressure, compromising venous blood flow, and limitingcapillary perfusion.capillary perfusion.

Leads toLeads to muscle ischemia and necrosis.

TRUE ORTHOPEDIC EMERGENCYTRUE ORTHOPEDIC EMERGENCYContributingFactors :ContributingFactors :

External :

Conditions thatConditions that reduced size of muscle compartmentreduced size of muscle compartment --tight casts / splints, occlusive dressing, burn scartight casts / splints, occlusive dressing, burn scar

Internal :Conditions thatConditions that increase compartment volumeincrease compartment volume ::

bleedingbleeding

swellingswelling

fluid extravasation into tissuefluid extravasation into tissue


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CS - Common in crush injuries or # with marked swelling.

- much more often in lower (rather than upper) extremities.


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Compartment Syndrome :Compartment Syndrome :

Recognition :Recognition :Suspect with long bone #, crush injuriesSuspect with long bone #, crush injuries

Presents as pain out of proportion to physicalPresents as pain out of proportion to physical

findings, +/findings, +/-- hypoesthesia, pulselessness (late).hypoesthesia, pulselessness (late).

Management :Management :

Remove compressive dressings or casts

Apply ice to the affected extremity, do no

elevate- keeping the area dependant will

increase the perfusion pressure

Treatment emergent fasciotomy


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THANK YOUTHANK YOU


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GUSTILLOS CLASSIFICATION OFOPENGUSTILLOS CLASSIFICATION OFOPEN

FRACTURE :FRACTURE :

Grade I :Grade I : -- woundwound < 1 cm,< 1 cm, minimal STI & comminution-- wound bed is clean ; bone injury is simplewound bed is clean ; bone injury is simple-- with IM nailing, average time to union is 21with IM nailing, average time to union is 21--28 weeks;28 weeks;

Grade II :Grade II : -- wound iswound is 11 10 cm,10 cm, moderate STI & contaminationmoderate STI & contamination ,,comminutioncomminution

-- with IM nailing, average time to union is 26with IM nailing, average time to union is 26--28 weeks;28 weeks;

Grade III :Grade III :-- segmental # with displacement, # with diaphyseal segmental loss, # withsegmental # with displacement, # with diaphyseal segmental loss, # withassociated vascular injury requiring repair;associated vascular injury requiring repair;-- highly contaminated woundshighly contaminated wounds

Grade IIIA # :Grade IIIA # :-- woundwound > 10 cm,> 10 cm, crushed tissue and contamination;crushed tissue and contamination;

-- soft tissue coverage of bone is usually possible;soft tissue coverage of bone is usually possible;-- with IM nailing, average time to union is 30with IM nailing, average time to union is 30--35 weeks;35 weeks;Grade IIIB # :Grade IIIB # :

-- wound > 10 cm, crushed tissue and contamination;wound > 10 cm, crushed tissue and contamination;-- soft tissue issoft tissue is inadequateinadequate and requires regional or free flapand requires regional or free flap-- with IM nailing, average time to union is 30with IM nailing, average time to union is 30--35 weeks;35 weeks;

Grade IIIC # :Grade IIIC # :

-- involvinginvolving major vascular injurymajor vascular injury requiring repair for limb salvagerequiring repair for limb salvage


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Approach to Fracture Bone