fracture managment

1. Basic Fracture
Management
Dr Tim Fletcher

2. Aims
 Clinical findings & diagnosis
 Basic acute fracture management
 Common fracture patterns
 XR recognition
 Neurovascular assessment of upper & lower
limbs
 Compartment syndrome

3. Who gets
fractures……?

4.  Kids

5.  Sport injuries

6.  Trauma

7. Clinical history & examination
 Pain
 Weightbearing status
 Occupation
 Dominant hand
 Fasting status
 Tenderness
 Swelling
 Soft Tissue
- COMPOUND ???
 Deformity
 Neurovascular status

8. Compound Fractures
 Grade I/II/III
 Washout saline
 Betadine dressing
 Tetanus
 IV abtx
 Cephazolin
 Flagyl
 Gentamycin

10. Deformity
 ? Dislocation/ Fracture dislocation
 ? Neurovascular compromise
 Management = pull it/straighten it/stabilise it
 Fentanyl/Midazolam/Oxygen
 Ketamine
 Airway trolley

12. Fracture complications
 Local pressure
 Lacerations
 Compartment syndrome

13.  Midshaft humeral #
 Radial nerve at risk
 Extension of wrist/digits
 Mx: hanging cast

14. Compartment Syndrome
 History
 Clinical
 Traditional 5 P’s – only for the fool hardy
 Presence of a pulse does not exclude CS
 Most reliable:
passive stretching
pain on palpation involved compartment
sensory deficit

15. Compartment Syndrome
 Compartment Pressure
 Tissue pressures > 35-45 mm Hg
 Be aware of systemic blood pressure
 A difference of less than 30 mmHg between tissue
pressure and the diastolic pressure indicates need for
fasciotomy
McQueen M, Acta Chir Belg 1998 Aug ; 98(4):166-70
 High clinical suspicion

16. Common fractures
 Colles fracture
 ‘dinner fork’ deformity
 Radial & dorsal displacement of distal fragment
 Radial angulation od distal fragment
 Dorsal displacment of distal fragment
 Shortening of radius compared to ulna

19. Monteggia Fracture

20. Galeazzi Fracture
 Fracture radial shaft
 Dislocation of DRUJ (distal radial ulna junction)

21.  Pathological fracture
 History
 XR full length of bone
 Bone scan

22.  AC joint dislocation
 6 grades
 Tx: broad arm sling

23. Pelvic Fractures
 Stable
 Pubic rami fractures
 Unstable
 Significant force
 Anterior & posterior fracture
 Haemodynamic compromise

24. Pelvic fracture
 Management
 MAST suit
 Simple bed sheet
 Referral
 Dangers
 Urethral damage
 Retrograde urethrogram

30. Traumatic Hip Dislocation
 Anterior Hip Dislocation
 High-energy
 Younger pts
 Ext rotation/flexion
 Posterior hip Dislocation
 Internal rotation
 THRs
 DANGER AVN >6/24

31.  Posterior Dislocation  Anterior dislocation

33. Fractures NOF
 GOMER population
 Classification
 Intracapsular
 GARDEN CLASSIFICATION
 I: incomplete fracture/valgus impaction
 II: complete fracture without displacement
 III: complete fracture with minimal displacment
 IV: complete fracture with ‘off ending’
 Extracapsular
 Intertorchanteric
 Subtrochanteric

34. Clinical appearnace
 Shortening
 Ext rotation
 Neurovascular status
 Management
 Analgesia
+/- skin traction
 OT

35.  Intertrochanteric
 No risk of AVN
 Richards Pin &
plate

36.  Richard’s Pin &
plate
 Dynamic Hip
Screw (DHS)

37.  Garden IV
 Femoral head
necrosis
 Hemiarthroplasty

38.  Thompson’s
Hemiarhtroplasty

39. Femoral Shaft Fractures
 High energy
 Clinical deformity
 Blood loss (1.5 litres)
 Neurovascular status
 Traction always must be applied
 Donway splint
 Thomas traction

41.  Thomas Splint

42.  RIGHT
Comminuted midshaft
fracture femur
 LEFT
3 part fracture midshaft

43. Ankle Fractures
 Clinical presentation
 Non-weight bearing
 Swollen
 Deformity
 Pain

44. Ottawa Ankle rules
 An XR is needed only if one positive
 Tenderness head of fibula
 Tenderness posterior lip of MM/LM
 Tenderness base 5th Metatarsal
& inability to weight bear both immediately & in ED

45. Weber Classification
 Weber A
-Below level of mortice C
 Weber B
-level of syndesmosis B
 Weber C
- Above level of syndesmosis A

46.  Weber B with medial
malleolar avulsion
fracture

48. FUBAR Classification

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