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Principles in fractures management

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Presented at AW Sjahranie Hospital under supervision of dr. David SpOT

Presented at AW Sjahranie Hospital under supervision of dr. David SpOT

Published in: Health & Medicine

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  • 1. PRINCIPLES IN FRACTURES MANAGEMENT ISA BASUKI
  • 2. DEFINITION OF FRACTURE • A FRACTURE IS A BREAK IN THE STRUCTURAL CONTINUITY OF BONE. • IF THE OVERLYING SKIN REMAINS INTACT IT IS A CLOSED (OR SIMPLE) FRACTURE • IF THE SKIN OR ONE OF THE BODY CAVITIES IS BREACHED IT IS AN OPEN (OR COMPOUND) FRACTURE • FRACTURES RESULT FROM: 1. INJURY 2. REPETITIVE STRESS 3. ABNORMAL WEAKENING OF THE BONE (A ‘PATHOLOGICAL’ FRACTURE)
  • 3. FRACTURES DUE TO INJURY
  • 4. FATIGUE OR STRESS FRACTURES • BONE , LIKE OTHER MATERIALS , REACTS TO REPEATED LOADING . • ON OCCASION , IT BECOMES FATIGUED & A CRACK DEVELOPS • E.G MILITARY INSTALLATIONS , BALLET DANCERS & ATHLETES. • A SIMILAR PROBLEM OCCURS IN INDIVIDUALS WHO ARE ON MEDICATION THAT ALTERS THE NORMAL BALANCE OF BONE RESORPTION AND REPLACEMENT • E.G. PATIENTS WITH CHRONIC INFLAMMATORY DISEASES WHO ARE ON TREATMENT WITH STEROIDS OR METHOTREXATE
  • 5. PATHOLOGICAL FRACTURES • FRACTURES MAY OCCUR EVEN WITH NORMAL STRESSES IF THE BONE HAS BEEN WEAKENED BY A CHANGE IN ITS STRUCTURE • E.G. IN OSTEOPOROSIS, OSTEOGENESIS IMPERFECTA OR PAGET’S DISEASE • OR THROUGH A LYTIC LESION • E.G. A BONE CYST OR A METASTASIS.
  • 6. DIAGNOSIS •CLINICAL FEATURES •RADIOLOGY (X-RAY)
  • 7. CLINICAL FEATURES • HISTORY OF TRAUMA • SYMPTOMS AND SIGNS: 1. PAIN AND TENDERNESS 2. SWELLING 3. DEFORMITY 4. CREPITUS 5. LOSS OF FUNCTION 6. NERVE AND VASCULAR INJURY
  • 8. RADIOGRAPHIC FINDINGS • PLAIN X-RAY  SHOULD SHOW JOINT ABOVE AND JOINT BELOW IN AT LEAST 2 VIEWS, SPECIAL VIEW ON REQUEST • CT SCAN • MRI  IT IS NOT HELPFUL IN FRACTURE DIAGNOSIS OTHER THAN DELINEATING ASSOCIATED INJURIES TO THE CNS , SUBTROCHANTERIC (ST) DISRUPTION OR OCCASIONALLY FATIGUE FRACTURE
  • 9. FRACTURE CLASSIFICATION • ANATOMICAL LOCATION • CONDITION OF OVERLYING ST • DIRECTION OF FRACTURE LINE • MECHANISM OF INJURY • WHETHER THE FRACTURE IS LINEAR OR COMMINUTED • AO CLASSIFICATION
  • 10. AO CLASSIFICATION •A: SIMPLE FRACTURE •B: WEDGE FRACTURE •C: COMPLEX FRACTURE
  • 11. AO CLASSIFICATION A= simple fract. A1 simple fract. Spiral A2 simple fract. Oblique(≥30) A3 simple fract. Transverse(<30)
  • 12. AO CLASSIFICATION B1 wedge fract Spiral wedge B2 wedge fract Bending wedge B= Wedge fract. B1 wedge fract Spiral wedge B2 wedge fract Bending wedge B3 wedge fract fragmented wedge
  • 13. AO CLASSIFICATION C= complex fract. C1 complex fract. spiral C2 complex fract. segmental C3 complex fract. irregular
  • 14. OPEN AND CLOSE FRACTURE
  • 15. MECHANISM OF INJURY CLASSIFICATION •DIRECT TRAUMA •INDIRECT TRAUMA
  • 16. DIRECT TRAUMA • TAPPING FRACTURES • CRUSHING FRACTURES • PENETRATING FRACTURES: • HIGH VELOCITY  > 2500 F/S • LOW VELOCITY  < 2500 F/S
  • 17. INDIRECT TRAUMA • TRACTION OR TENSION FRACTURES • ANGULATION FRACTURES • ROTATIONAL FRACTURES • COMPRESSION FRACTURES
  • 18. FRACTURE MANAGEMENT •TREATMENT OF CLOSED FRACTURES •TREATMENT OF OPEN FRACTURES
  • 19. TREATMENT OF CLOSED FRACTURES •EMERGENCY CARE (SPLINTING) •DEFINITIVE FRACTURE TREATMENT •REHABILITATION (MUSCLE ACTIVITY AND EARLY WEIGHTBEARING ARE ENCOURAGED)
  • 20. EMERGENCY CARE (SPLINTING) • SPLINT THEM WHERE THEY LIE • ADEQUATE SPLINTING IS DESIRABLE • TYPE OF SPLINTS: • IMPROVISED • CONVENTIONAL
  • 21. DEFINITIVE FRACTURE TREATMENT • THE GOAL OF FRACTURE TREATMENT IS TO OBTAIN UNION OF THE FRACTURE IN THE MOST ANATOMICAL POSITION COMPATIBLE WITH MAXIMAL FUNCTIONAL RETURN OF THE EXTREMITY • 2 TYPES OF DEFINITIVE FRACTURE TREATMENT: • CONSERVATIVE • SURGICAL
  • 22. CONSERVATIVE • REDUCTION: IF DISPLACED  UNDER GENERAL ANASTHESIA, THE SOONER THE BETTER • STEPS OF REDUCTION: • TRACTION • ALIGN (WHICH FRAGMENT) • REVERSE MECHANISM OF INJURY • IMMOBILIZATION: POP (PLASTER OF PARIS) CAST, SLAB, TRACTION (FIXED OR BALANCED) • REHABILITATION
  • 23. CLOSED REDUCTION TRACTION IN THE LINE OF THE BONE DISIMPACTION PRESSING FRAGMENT INTO REDUCED POSITION
  • 24. CLOSED UNDISPLACED CLOSED, REDUCIBLE  CONSERVATIVE TREATMENT Below knee Above knee
  • 25. PLASTER OF PARIS (POP)
  • 26. SLAB OR SPLINT
  • 27. TRACTION
  • 28. SURGICAL •OPEN REDUCTION INTERNAL FIXATION (ORIF) •PERCUTANEOUS PINNING •EXTERNAL FIXATION
  • 29. OPEN REDUCTION INDICATIONS • OPERATIVE REDUCTION OF THE FRACTURE IS INDICATED: 1.WHEN CLOSED REDUCTION FAILS 2.WHEN THERE IS A LARGE ARTICULAR FRAGMENT THAT NEEDS ACCURATE POSITIONING 3.FOR TRACTION (AVULSION) FRACTURES IN WHICH THE FRAGMENTS ARE HELD APART
  • 30. INTERNAL FIXATION INDICATION 1. FRACTURES THAT CANNOT BE REDUCED EXCEPT BY OPERATION 2. FRACTURES THAT ARE INHERENTLY UNSTABLE AND PRONE TO RE-DISPLACE AFTER REDUCTION 3. FRACTURES THAT UNITE POORLY AND SLOWLY 4. PATHOLOGICAL FRACTURES IN WHICH BONE DISEASE MAY PREVENT HEALING 5. MULTIPLE FRACTURES WHERE EARLY FIXATION REDUCES THE RISK OF GENERAL COMPLICATIONS AND LATE MULTISYSTEM ORGAN FAILURE 6. FRACTURES IN PATIENTS WHO PRESENT NURSING DIFFICULTIES
  • 31. TYPE OF INTERNAL FIXATION • INTERFRAGMENTARY SCREWS • WIRES (TRANSFIXING, CERCLAGE AND TENSION- BAND) • PLATES AND SCREWS • INTRAMEDULLARY NAILS
  • 32. PLATES AND SCREWS • PLATES HAVE FIVE DIFFERENT FUNCTIONS: 1. NEUTRALIZATION • TO BRIDGE A FRACTURE AND SUPPLEMENT THE EFFECT OF INTERFRAGMENTARY LAG SCREWS 2. COMPRESSION • USED IN METAPHYSEAL FRACTURES WHERE HEALING ACROSS THE CANCELLOUS FRACTURE GAP MAY OCCUR DIRECTLY 3. BUTTRESSING • ‘OVERHANG’ OF THE EXPANDED METAPHYSES OF LONG BONES 4. TENSION-BAND • ALLOWS COMPRESSION TO BE APPLIED TO THE BIOMECHANICALLY MORE ADVANTAGEOUS SIDE OF THE FRACTURE 5. ANTI-GLIDE • TO PREVENT SHORTENING AND RECURRENT DISPLACEMENT OF THE FRAGMENTS
  • 33. INTRA-MEDULLARY FIXATION • CENTRO-MEDULLARY • UNLOCKED • INTERLOCKING (STATIC – DYNAMIC – DOUBLE LOCKED) • CONDYLOCEPHALIC • CEPHALLOMEDULLARY
  • 34. AN OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR, BEFORE AND AFTER REAMED INTRAMEDULLARY FIXATION WITH A STOUT NAIL AND INTERLOCKING SCREWS. THIS TREATMENT ALLOWS NEAR IMMEDIATE AMBULATION FOR THE PATIENT.
  • 35. EXTERNAL FIXATION • INDICATIONS: 1. FRACTURES ASSOCIATED WITH SEVERE SOFT-TISSUE DAMAGE (INCLUDING OPEN FRACTURES) OR THOSE THAT ARE CONTAMINATED 2. FRACTURES AROUND JOINTS THAT ARE POTENTIALLY SUITABLE FOR INTERNAL FIXATION BUT THE SOFT TISSUES ARE TOO SWOLLEN TO ALLOW SAFE SURGERY 3. PATIENTS WITH SEVERE MULTIPLE INJURIES 4. UNUNITED FRACTURES, WHICH CAN BE EXCISED AND COMPRESSED 5. INFECTED FRACTURES
  • 36. REHABILITATION • RESTORE FUNCTION – NOT ONLY TO THE INJURED PARTS BUT ALSO TO THE PATIENT AS A WHOLE • THE OBJECTIVES ARE: 1. TO REDUCE OEDEMA 2. PRESERVE JOINT MOVEMENT 3. RESTORE MUSCLE POWER 4. GUIDE THE PATIENT BACK TO NORMAL ACTIVITY
  • 37. TREATMENT OF OPEN FRACTURES •INITIAL MANAGEMENT •CLASSIFYING THE INJURY •DEFINITIVE TREATMENT
  • 38. INITIAL MANAGEMENT • IT IS ESSENTIAL THAT THE STEP-BY-STEP APPROACH IN ADVANCED TRAUMA LIFE SUPPORT NOT BE FORGOTTEN • WHEN THE FRACTURE IS READY TO BE DEALT WITH: 1. THE WOUND IS CAREFULLY INSPECTED 2. ANY GROSS CONTAMINATION IS REMOVED 3. THE WOUND IS PHOTOGRAPHED 4. THE AREA THEN COVERED WITH A SALINE-SOAKED DRESSING 5. THE PATIENT IS GIVEN ANTIBIOTICS 6. TETANUS PROPHYLAXIS IS ADMINISTERED 7. THE LIMB CIRCULATION AND DISTAL NEUROLOGICAL STATUS CHECKED REPEATEDLY
  • 39. CLASSIFYING THE INJURY • WITH GUSTILO’S CLASSIFICATION OF OPEN FRACTURES (GUSTILO ET AL., 1984): • TYPE 1 – THE WOUND IS USUALLY A SMALL, CLEAN PUNCTURE THROUGH WHICH A BONE SPIKE HAS PROTRUDED. THERE IS LITTLE SOFT-TISSUE DAMAGE WITH NO CRUSHING AND THE FRACTURE IS NOT COMMINUTED (I.E. A LOW-ENERGY FRACTURE). • TYPE II – THE WOUND IS MORE THAN 1 CM LONG, BUT THERE IS NO SKIN FLAP. THERE IS NOT MUCH SOFT-TISSUE DAMAGE AND NO MORE THAN MODERATE CRUSHING OR COMMINUTION OF THE FRACTURE (ALSO A LOW- TO MODERATE- ENERGY FRACTURE). • TYPE III – THERE IS A LARGE LACERATION, EXTENSIVE DAMAGE TO SKIN AND
  • 40. CLASSIFYING THE INJURY • THERE ARE THREE GRADES OF SEVERITY: • TYPE III A  THE FRACTURED BONE CAN BE ADEQUATELY COVERED BY SOFT TISSUE DESPITE THE LACERATION. • TYPE III B  THERE IS EXTENSIVE PERIOSTEAL STRIPPING AND FRACTURE COVER IS NOT POSSIBLE WITHOUT USE OF LOCAL OR DISTANT FLAPS. • TYPE III C  THERE IS AN ARTERIAL INJURY THAT NEEDS TO BE REPAIRED, REGARDLESS OF THE AMOUNT OF OTHER SOFT-TISSUE DAMAGE
  • 41. PRINCIPLES OF TREATMENT • ALL OPEN FRACTURES, NO MATTER HOW TRIVIAL THEY MAY SEEM, MUST BE ASSUMED TO BE CONTAMINATED • THE FOUR ESSENTIALS ARE: 1. ANTIBIOTIC PROPHYLAXIS. 2. URGENT WOUND AND FRACTURE DEBRIDEMENT. 3. STABILIZATION OF THE FRACTURE. 4. EARLY DEFINITIVE WOUND COVER.
  • 42. WOUND EXTENSIONS FOR ACCESS IN OPEN FRACTURES OF THE TIBIA WOUND INCISIONS (EXTENSIONS) FOR ADEQUATE ACCESS TO AN OPEN TIBIAL FRACTURE ARE MADE ALONG STANDARD FASCIOTOMY INCISIONS: 1 CM BEHIND THE POSTEROMEDIAL BORDER OF THE TIBIA AND 2–3 CM LATERAL TO THE CREST OF THE TIBIA AS SHOWN IN THIS EXAMPLE OF A TWO-INCISION FASCIOTOMY. THE DOTTED LINES MARK OUT THE CREST (C) AND POSTEROMEDIAL CORNER (PM) OF THE TIBIA THESE INCISIONS AVOID INJURY TO THE PERFORATING BRANCHES THAT SUPPLY AREAS OF SKIN THAT CAN BE USED AS FLAPS TO COVER THE EXPOSED FRACTURE THIS CLINICAL EXAMPLE SHOWS HOW LOCAL SKIN NECROSIS AROUND AN OPEN FRACTURE IS EXCISED AND THE WOUND EXTENDED PROXIMALLY ALONG A
  • 43. • THE EXTERNAL FIXATOR MAY BE EXCHANGED FOR INTERNAL FIXATION AT THE TIME OF DEFINITIVE WOUND COVER AS LONG AS: 1. THE DELAY TO WOUND COVER IS LESS THAN 7 DAYS 2. WOUND CONTAMINATION IS NOT VISIBLE 3. INTERNAL FIXATION CAN CONTROL THE FRACTURE AS WELL AS THE EXTERNAL FIXATOR
  • 44. AFTERCARE • IN THE WARD, THE LIMB IS ELEVATED AND ITS CIRCULATION CAREFULLY WATCHED. • ANTIBIOTIC COVER IS CONTINUED BUT ONLY FOR A MAXIMUM OF 72 HOURS IN THE MORE SEVERE GRADES OF INJURY • WOUND CULTURES ARE SELDOM HELPFUL, IF IT WERE TO ENSUE, IS OFTEN CAUSED BY HOSPITAL-DERIVED ORGANISMS
  • 45. REFERENCES 1. SOLOMON L, WARWICK DJ, NAYAGAM S. APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES. CRC PRESS; 2010. 2. F. CHARLES BRUNICARDI, DANA K. ANDERSEN, TIMOTHY R. BILLIAR, DAVID L. DUNN, JOHN G. HUNTER, RAPHAEL E. POLLOCK, ET AL. SCHWARTZ’S PRINCIPLES OF SURGERY. 9TH ED. NEW YORK/US: MCGRAW-HILL EDUCATION - EUROPE; 2009.