1. POP application course
18th December 2006
An Overview on
Fractures Care
Dr. Rashidi Ahmad
MD USM, MMED USM, FADUSM
Lecturer/Emergentist
USM Health Campus
2. Objectives
• To increase an awareness the
importance of appropriate care of
fracture
• To increase understanding on fracture
management
• To gain more knowledge & skill – to
make right decision & to perform the
proper action
3. Outline
• Understanding fractures
• Describing fractures based on clinical
presentations & radiological features
• Principles of fracture management
4. Trauma patient is an injured person who
requires timely diagnosis and treatment
of actual or potential injuries by a
multidisciplinary team of health care
professionals, supported by the
appropriate resources, to diminish or
eliminate the risk of death or permanent
disability.
Europian Trauma Life Support
6. Fracture?
• A fracture is a disruption in the
integrity of a living bone involving
injury to bone marrow, periosteum,
and adjacent soft tissues.
10. Life threatening fractures
• Le Fort II/III fracture & bilateral mandible fracture with
airway compromised
• Upper cervical fracture & flail chest with impaired
ventilation
• Pelvic & open fractures with vascular injury/shock
• Untreated multiple long bones fracture with fat
embolism
• Depressed skull fracture with extradural bleeding
17. 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
– BS (scaphoid, talus, femoral and humeral head)
– NS
– No infection
• The patient
• The method of treatment
18. 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
19. Prehospital care
• First aid principles
• Preliminary splinting/sling of the injured
extremity
- reduces pain
- reduces damage to nerve & vessels
- reduces risk of conversion to open fracture
- facilitates transportation & x-ray taking.
24. Prehospital reduction
• Prehospital reduction of deformity – by
advice of physician
• Obvious fracture along the shaft of a
long bone with a neurovascular deficit –
longitudinal traction
• Deformity near a joint – possibility of
dislocation
25. Careful history
• Precise MOI
• Listen carefully to the patient’s symptoms
• Why?
- Pain of fracture may be referred to another
area
- Specific x-ray view is indicated by proper
history
- Some injuries may not be radiologically
apparent on the 1st day
33. Physical examination
• Inspection for swelling, discoloration,
deformity
• Assessment of active & passive ROM of
the joints proximal & distal to the injury
• Palpation for tenderness
• Verification of neurovascular status
34. Radiologic evaluation
• X-ray is an important adjunct
• Ordered based on Hx & PE
• 2 views – AP & lateral
• 2 joints – above & below the shaft
fracture
• In children with injury near the joint –
bilateral x-rays for comparison
• Repeat x-rays after 1 – 2 weeks to show
callus in doubtful fractures
35. Describing fractures
• Open versus closed
• Location of the fracture
• Orientation of the fracture line
• Displacement & separation
• Angulation
• Shortening
• Rotational deformity
• Fracture – dislocation/subluxation
• Salter fractures
• Fragmentation
• Soft tissue involvement
56. Fragmentation
The Muller AO Comprehensive Classification of Fractures
- A multi-fragmentary fracture: several breaks (>2
fragments) in the bone
- Wedge fractures: spiral (low energy) @ bending
(high energy
- The complex multi-fragmentary fracture: segmental
fracture in which there is no contact between the
proximal & distal fragments, no bone shortening.
- Simple fractures are spiral, oblique, or transverse.
58. Soft tissue involvement
Gustilo. Current Concepts: the management of open fractures.
JBJS (1990); 72A; 299-304
• Minor / Grade I - small punctate wound <1 cm a/w low velocity
trauma. Minimal soft tissue injury. No crushing. No comminution.
• Moderate / Grade II – extensive wounds with relatively little soft
tissue damage, and only moderate crushing or comminution.
• Major / Grade III - wounds of moderate or massive size with
considerable soft tissue injury and/or foreign body contamination:
• III A - sufficient soft tissue to cover the fracture
• III B - insufficient tissue to cover the fracture; also periosteal
stripping and severe comminution
• III C - arterial damage requiring repair. Degree of soft tissue
damage not considered
61. General management of
patients with fracture
• Life saving measures
- Primary & secondary survey
- Emergency orthopaedic involvement
–Life saving
–Complication saving
62. Cont…
• Emergency orthopedic management
- Control of pain & swelling
- Keep NBM if GA @ PCS is required
- Reducing fracture deformity
- Tetanus prophylaxis
- Irrigation & debridement
- Antibiotic prophylaxis
• Conservative vs surgical management
• Monitoring of fracture
• Rehabilitation & Rx of complications
63. 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
64. 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
– Neurapraxias, axonotmesis, neurotmesis
• Ligaments
– Joint instability and dislocation
65. Treating the soft tissue injury
• All severe soft tissue injuries………require 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
66. Treating the fracture
• Purpose: to reduce, hold & maintain the # in a suitable
alignment
• Does the fracture require reduction? Displaced?
• Methods: CMR method by ACCROCHAGE and
continuous traction (skin & skeletal traction)
• What is acceptable # alignment?
• Consider: age, site, weight bearing, shortening,
angulation & rotation
67. Risk benefit
Operative Non-operative
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 ? ?
68. Treating the fracture
• 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?
71. 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 injury or compartment
syndrome
– Pathological #’s, Non-unions
72. Indications for operative treatment
• 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
73. 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
74. Rehabilitation
• Restoring the patient as close to pre-injury
functional level as possible
• Approach needs to be:-
–Pragmatic with realistic targets
–Multidisciplinary: Physiotherapist,
Occupational therapist, District nurse,
GP, Social worker
75. Summary
• Fractures are a/w mortality & morbidity
• Fractures care starts from the onset till fully
recover
• Primary survey + resuscitation are the
PRIORITY
• Do not underestimate the benefit of
reassurance, pain management & splinting
• Multidiscipline approach