Fractures, bone healing & principles of tx. of fractures

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Fractures, bone healing & principles of tx. of fractures

  1. 1. Fractures and Bone Healing Dr. Muhammad Salman
  2. 2. Statistics • Fractures of extremities most common • More common in men up to 45 years of age • More common in women over 45 years of age Before 75 years wrist fractures (Colles‟) most common • After 75 years hip fractures most common
  3. 3. Types of fractures  Magnitude and direction of force  Closed – Bone fragments do not pierce skin  Open/compound – Bone fragments pierce skin  Displaced or undisplaced
  4. 4. Transverse fracture  Usually caused by directly applied force to fracture site
  5. 5. Spiral or Oblique  Caused by violence transmitted through limb from a distance (twisting movements)
  6. 6. Greenstick  Occurs in children: bones soft and bend without fracturing completely
  7. 7. Crush fractures  Fracture in cancellous bone: result of compression (osteoporosis)
  8. 8. Avulsion fracture  Caused by traction, bony fragment usually torn off by a tendon or ligament.  What muscle group attaches to this bony prominence and what nerve also runs in close proximity?  Forearm flexors (common flexor origin) ulnar nerve
  9. 9. Fracture dislocation/subluxation  Fracture involves a joint: results in malalignment of joint surfaces.
  10. 10. Impacted fracture  Bone fragments are impacted into each other.
  11. 11. Comminuated fracture  Two or more bone pieces - high energy trauma
  12. 12. Comminuated fractures can require serious hardware to repair.
  13. 13. Stress fracture  Abnormal stress on normal bone (fatigue fracture) or normal stress on abnormal bone (insufficiency fracture).
  14. 14. Functions of the X-ray  Localises fracture and number of fragments  Indicates degree of displacement  Evidence of pre-existing disease in bone  Foreign bodies or air in tissues  May show other fractures  MRI, CT or ultrasound to reveal soft tissue damage
  15. 15. How to Handle Fractures  Reduction  Open reduction – Allows very accurate reduction – Risk of infection – Usually when internal fixation is needed  Manipulation – Usually with anaesthesia  Traction – Fractures or dislocation requiring slo
  16. 16. Holding the reduction  4-12 weeks  External fixation  Internal fixation – Intermedually nails, compression plates  Frame fixation
  17. 17. External fixation  Used for fractures that are too unstable for a cast. You can shower and use the hand gently with the external fixator in place.
  18. 18. Frame fixation  Allows correction of deformities by moving the pins in relation to the frame.
  19. 19. Internal fixation
  20. 20. Bone Healing 1. Fracture hematoma – blood from broken vessels forms a clot. – 6-8 hours after injury – swelling and inflammation to dead bone cells at fracture site
  21. 21. 2. Fibrocartilaginous callus  (lasts about 3 weeks (up to 1st May)) – new capillaries organise fracture hematoma into granulation tissue - „procallus‟ – Fibroblasts and osteogenic cells invade procallus. – Make collagen fibres which connect ends together – Chondroblasts begin to produce fibrocatilage,
  22. 22. 3. Bony callus  (after 3 weeks and lasts about 3-4 months) – osteoblasts make woven bone.
  23. 23. 4. Bone Remodeling  Osteoclasts remodel woven bone into compact bone and trabecular bone – Often no trace of fracture line on X-rays.
  24. 24. PRINCIPLES OF TREATMENT OF FRACTURES
  25. 25. GOALS OF FRACTURE TREATMENT  Restore the patient to 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
  26. 26. HOW FRACTURES HEAL In nature  Regeneration vs repair  Three phases of healing by callus  Rapid process, rehabilitation slow, low risk With operative intervention (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
  27. 27. FACTORS AFFECTING FRACTURE HEALING  The energy transfer of the injury  The tissue response  Two bone ends in opposition or compressed  Micro-movement or no movement  Blood Supply (scaphoid, talus, femoral and humeral head)  Nerve Supply  No infection  The patient  The method of treatment
  28. 28. HIGH-ENERGY INJURY
  29. 29. LOW ENERGY INJURY
  30. 30. DESCRIBING THE FRACTURE Mechanism of injury (traumatic, pathological, stress)  Anatomical site (bone and location in bone)  Configuration Displacement  three planes of angulation  translation  shortening  Articular involvement/epiphyseal injuries  fracture involving joint  dislocation  ligamentous avulsion  Soft tissue injury
  31. 31. MINIMALLY DISPLACED DISTAL RADIUS FRACTURE
  32. 32. COMMINUTED PROXIMAL- THIRD FEMORAL FRACTURE WITH SIGNIFICANT DISPLACEMEN T
  33. 33. MANAGEMENT OF THE INJURED PATIENT  Life saving measures  Diagnose and treat life threatening injuries  Emergency orthopaedic involvement  Life saving  Complication saving  Emergency orthopaedic management (Day 1)  Monitoring of fracture (Days to weeks)  Rehabilitation + treatment of complications (weeks to months)
  34. 34. LIFE SAVING MEASURES  A Airway and cervical spine immobilisation  B Breathing  C Circulation (treatment and diagnosis of cause)  D Disability (head injury)  E Exposure (musculo-skeletal injury)
  35. 35. EMERGENCY ORTHOPAEDIC MANAGEMENT  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
  36. 36. DIAGNOSING THE SOFT TISSUE INJURY  Skin  Open fractures, degloving injuries and ischaemic necrosis  Muscles  Crush and compartment syndromes  Blood vessels  Vasospasm and arterial laceration  Nerves  Ligaments  Joint instability and dislocation
  37. 37. SEVERE SOFT-TISSUE INJURY
  38. 38. TREATING THE SOFT TISSUE INJURY  All severe soft tissue injuries………equire urgent treatment  Open fractures , Vascular injuries, Nerve injuries, Compartment syndromes, Fracture/dislocations  After the treatment of the soft tissue injury the fracture requires rigid fixation  A severe soft-tissue injury will delay fracture healing
  39. 39. DIAGNOSING THE BONE INJURY  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
  40. 40. TREATING THE FRACTURE I  Does the fracture require reduction?  Is it displaced?  Does it need to be reduced? (e.g. clavicle, ribs, MT‟s)  How accurate a reduction do we need?  alignment without angulation (closed reduction - e.g. wrist)  anatomic (open reduction - e.g. adult forearm )
  41. 41. TREATING THE FRACTURE II  How are we going to hold the reduction?  Semi-rigid (Plaster)  Rigid (Internal fixation)  What treatment plan will we follow?  When can the patient load the injured limb?  When can the patient be allowed to move the joints?  How long will we have to immobilise the fracture for?
  42. 42. DIFFERENT TYPES OF RIGID FRACTURE FIXATION
  43. 43. TREATING THE FRACTURE III Operative Non-optve 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 ? ?
  44. 44. INDICATIONS FOR OPERATIVE TREATMENT  General trend toward operative treatment last 30 yrs  Improved implants and antibiotic prophylaxis, Use of closed and minimally invasive methods  Current absolute indications:-  Polytrauma Displaced intra-articular fractures  Open #‟s #‟s with vascular inj or compartment syn, Pathological #‟s Non-unions  Current relative indications:-  Loss of position with closed method, Poor functional result with non-anatomical reduction, Displaced fractures with poor blood supply, Economic and medical indications
  45. 45. WHEN IS THE FRACTURE HEALED?  Clinically Upper limb Lower limb Adult 6-8 weeks 12-16 weeks Child 3-4 weeks 6-8 weeks  Radiologically  Bridging callus formation  Remodelling
  46. 46. REHABILITATION  Restoring the patient as close to pre-injury functional level as possible  May not be possible with:-  Severe fractures or other injuries  Frail, elderly patients  Approach needs to be:-  Pragmatic with realistic targets  Multidisciplinary  Physiotherapist, Occupational therapist, District nurse, GP, Social worker
  47. 47. COMPLICATIONS OF FRACTURES Early Late General Other injuries Chest infection PE UTI ARDS Bed sores Bone Infection Non-union Malunion Soft-tissues Plaster sores Tendon rupture N/V injury Nerve compression Compartment syn. Volkmann contracture
  48. 48. Enough for today….!!! 

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