![ROCKVIEW UNIVERSITY
SCHOOL OF HEALTH SCIENCES
DIPLOMA IN CLINICAL MEDICINE
[SURG-2310]
TOPIC:FRACTURES (#s)
LECTURER:MLP MBAMBARA](https://image.slidesharecdn.com/fractures-231022103704-f39bd5c6/85/fracturespptx-1-320.jpg)
Recommended
More Related Content
Similar to Fractures.pptx
Similar to Fractures.pptx (20)
Recently uploaded
Recently uploaded (20)
Fractures.pptx
- 1. ROCKVIEW UNIVERSITY SCHOOL OF HEALTH SCIENCES DIPLOMA IN CLINICAL MEDICINE [SURG-2310] TOPIC:FRACTURES (#s) LECTURER:MLP MBAMBARA
- 2. Outline Definition Aetiology Classification Clinical features Bone healing Investigations Principles of Management complications
- 3. Definition A fracture is a partial or complete break in the structural continuity of a bone with soft tissue involvement.
- 4. Aetiology 1.Traumatic fractures • Due to direct or indirect high force energy. 2.Stress fractures • Due to repetitive normal stress to a normal bone leading to fatigue and later fracture 3.Pathological fractures • Due to an abnormality (disease) of the bone • A trivial force applied to an abnormal bone leading to a fracture
- 5. Classification of Fractures 1.Clinical classification • Open and closed fractures 2.Anatomicla classification • Location of fracture on a bone 3.Radiological classification 4.Special classification
- 6. 1. Clinical Classification Closed (simple) fracture no communication between fracture site and skin surface. Open (compound) fracture communication between fracture site and skin surface Open fractures are classified by the Gustilo-Anderson’s classification system
- 7. 2. Anatomical Classification Diaphyseal fracture shaft of long bones can be proximal, mid-shaft or distal third Metaphyseal fracture part of the distal or proximal fractures of shaft Epiphyseal plate fracture Fracture of epiphyseal plate, mostly in young as the epiphysis is open and cartilaginous Classified by the Salter-Harris Condylar fractures
- 10. Types of Displacement Shortening Sideways shift. distraction Impaction Angulation Rotation
- 11. Special Classification a) Gustilo - Anderson classification of open fractures: Type I Clean wound < 1cm diameter, simple #, no skin crushing. There is mild contamination. Type II laceration > 1cm without significant soft tissue crushing, including no flaps, degloving or contusion. Moderate contamination Type III wound > 10cm with severe contamination plus extensive soft tissue injury. Also included are injuries older than 8 hours. It subdivided into 3 types:
- 12. Type IIIA Adequate soft tissue coverage of the # despite high energy trauma or extensive laceration or skin flaps. No periosteal stripping Type IIIB Inadequate soft tissue coverage with periosteal stripping. Soft tissue reconstruction is necessary. Type IIIC Any open # that is associated with neurovascular damage (arterial injury) that requires repair
- 13. c) Salter- Harris classification of #s involving epiphyseal plate: Type I - The # line passes cleanly along the epiphyseal line. Tends to occur in young children/babies and in pathological conditions e.g. spinal bifida or scurvy Type II - The commonest type, in which the # line runs across the epiphyseal line and then obliquely, shearing off a small triangle of metaphysis Type III - The epiphysis may be split vertically and a fragment displaced along the epiphyseal line Type IV - The # extends through the epiphyseal line from the metaphysis into the epiphysis. This type may interfere with growth because union may take place across the growth plate Type V - Severe crushing of the epiphysis may occur from longitudinal compression and this is very likely to result in growth arrest and deformity
- 14. d) Gartilands’ classification of supracondylar #: Type 1 - Undisplaced # Type 2 - Displaced # with intact posterior cortex Type 3 - Complete displacement #
- 15. e) Garden classification of neck of femur #s: Type1 - Incomplete or impacted fracture Media trabecular intact and vascularity preserved Type2 - Complete fracture without displacement Trabecular aligned and vscularity preserved Type3 - Complete fracture Partial displacement of < 50% diameter with trabeculae unaligned and damaged blood supply. Fracture fragment in connected by posterior retinacular attachment Type 4 - Complete fracture Complete displacement without trabecular alignment Vascular damage with ischemic
- 16. f) Boyd- griffin classification of intertrochanteric Fractures: Type1 - Undisplaced # Type2 - Partially displaced # Type3 - Reverse # Type4 - Displaced intertrochanteric # with subtrochanteric extension
- 17. g) Weber classification of Ankle #s: Type A - Below the syndesmosis Type B - At the syndesmosis Type C - Above the syndesmosis
- 18. Clinical Features History Circumstances surrounding the injury will help determine the extent of damage and associated complication Age and sex Pain, swelling, loss of function and symptoms of associated injuries Hx of trauma or not Past medical history (Previous injuries comorbidity) Drug history Gyn history General medical history
- 19. Clinical Features General signs level of consciousness signs haemorrhage or shock Associated damage to brain, spinal cord or viscera. look for swelling, bruising or lacerations Deformity such as Angulation, rotation, displacement, shortening Inability to use limb
- 20. Clinical Features Palpate for: Localized tenderness Warmth Distal pulses Sensation Crepitus Range of motion of associated joints
- 21. Bone Healing stages Haematoma formation tissue damage and bleeding. Inflammation stage inflammatory cells appear folloew bt granulation tissue Callus formation osteoblasts and osteoclasts appear leading to bone mineral deposited (woven bone ) Consolidation woven bone replaced by lamellar bone Remodelling new formed bone remodeled to resemble normal structure.(12-28 months)
- 24. FACTORS INFLUENCING BONE HEALING(SYSTEMIC) Age Hormones Functional activity Nerve function Nutrition Drugs(NSAID)
- 25. Local Factors Degree of local trauma Degree of bone loss Vascular injury Type of bone fractured Degree of immobilisation Infection Local pathological condition
- 26. Hormonal Influences On Bone Healing Cortisone decreases by decreasing callus formation Calcitoninincreases by unknown mechanism TH/PTH increases by bone remodelling Growth Hormone increases callus volume Androgensincreases callus volume
- 27. Investigations X-rays 1. Two views (AP & lateral) 2. Two joints (proximal and distal to #) 3. Two limbs (in children, epiphyses may confuse) 4. Two injuries (e.g. calcaneum vs pelvis/spine 5. Two occasions (repeat 10-14 days later)
- 28. Principles of Fracture Management Resuscitation – ABC’s Reduce (closed or open) Hold (immobilise) - continuous traction (skeletal vs skin) - splintage –plaster of paris( P.O.P) - functional bracing - [ORIF]Open reduction and internal fixation - external fixation Exercise Rehabilitate(preservation of function of the body part affected while the # is uniting and restoration of function after the fracture has united)
- 29. Irrigation Irrigation with normal saline or treated tap water for open fractures Type I – 3L ,Type II – 6L , Type III – 9L Debridement Meticulous excision of all dead and devitalised tissue upon arival and “Second-look” debridement to be routinely done after 48-72 hrs Start with the skin followed by fat and fascia, muscle, bone and others Irrigation and Debridement
- 30. Closed Reduction Indications Minimally displaced fractures Most fractures in children Fractures that are not unstable after reduction + can be held in splint or cast Unstable fractures prior to external or internal fixation NOTE;A Degloving injury is an avulsion wound.
- 31. Internal Fixation Indications Fractures that cannot be reduced except by operation Inherently unstable fractures Failure of conservative management Pathological fractures Multiple fractures Fractures with nursing difficulties NOTE;Peripheral aneurysm most commonly occurs in the popliteal artery
- 33. Broad spectrum antibiotics like 1st or 2nd generation cephalosporins Add an aminoglycoside for Type II or III Add penicillin if a farmyard injury 48-72hrs post-injury and again for 48-72hrs each time a procedure is done Prolonged use of antibiotics is not necessary Antibiotics
- 36. Clinical features of basal skull #s Symptoms Pain Dizziness Hx of amnesia (lucid interval) Hx of loss of consciousness Disorientation Nausea Seizures Vomiting Abnormal eye movements Signs Swelling Tenderness Bleeding from the skull Hearing loss CSF rhinorrhea CSF otorrhea Racoon eyes Battles sign
- 37. SKELETAL TRACTION 1. Perkins traction Is a type of skeletal traction with patient on Perkins bed and doing Perkins exercises?
- 38. State of the leg during Perkins traction a. Abducted = # of proximal 1/3rd of femur – to avoid angulation after healing b. Adducted/Straight = all other femur # Apply 1/7 of body wt. (adults) and raise foot end of bed by 4cm for each Kg This prevents over- traction & hence non- unions
- 39. When applying Perkins traction. Initially correct the shock if the pt. is in shock by giving blood Palpate the peripheral pulses Initial X-ray, take A-P and lateral view and the hip. Inset pin 2 cm distal to the tibial tuberosity
- 40. Apply wt. about 1/7 of the pts.’ wt. Raise the bed by about 4cm for each kg. Measure both the pts. legs from the anterior superior iliac spine to the tip of medial malleoli to make sure they are the same length. If necessary adjust the traction wt. and elevation of the foot end of the bed, so as to let the bony fragments overlap by about 1cm Check the leg length every day for the next 2 wks. and adjust the wts appropriately. Then you can check length every 2 wks.
- 41. Complications (i) Early (during insertion) complication - Damage to common peroneal nerve causing foot drop - Fat embolism - # of Tibia at the site of insertion of the pin - Soft tissue injury - Hemorrhage
- 42. Late complication (during Traction) Decubitus ulcers (Bed sores) Pin site infection- osteomyelitis Pin may become loose Osteoporosis- bone desorption to bed bound Over traction – causing non- union Malunion Delayed union Joint stiffness (ankylosis) Muscle disuse atrophy DVT Hypostatic pneumonia Contractures
- 43. Advantages Perkins exercise Increases blood supply Promote healing Controlled movement and compression of the bone ends encourages union Prevents muscle atrophy Prevents knees joint stiffness and contractures Prevents DVT, decubitus ulcers Prevents hypostatic pneumonia Encourages positive psychological effect on patient.
- 44. Indications Undisplaced incomplete # of the neck of the femur. All intertrochanteric fractures All # of the shaft of the femur in pts. over 18, e.g. overlapped, double, spiral, comminuted and open #s, and # with severe STI. Those supracondylar # in which the lower fragment has not been too severely flexed by the contraction of gastrocnemius -All condylar # of the femur, except those in which a condyle has rotated completely
- 45. Contraindications -All complete # of the neck of the femur -Displacement of the proximal femoral epiphysis -Subtrochanteric # with severe flexion of the proximal fragment -Supracondylar # with marked flexion of the distal fragment -Displacement of the distal femoral epiphysis
- 46. -# of the condyles in which a fragment has rotated completely -All pts. under 18. Their epiphyses will not have united and the pin may damage the epiphyseal plate. -Arthritis of the knee, or a stiff knee from any cause, which will make exercise impossible without moving the fragments too much. -Non-union in # treated by other methods.
- 47. Skin traction (1/10th of pts wt) Indications Extremes of age Children between 3 to 18 years (longitudinal bone growth may be arrest) Old people- fragile bones Those reacting to pin Fixed flexion deformity Fractures like Shaft of femur #s Intertrochanteric #s Upper femoral epiphysis separation An unstable hip after reduction of a dislocation
- 48. Types of skin traction. Gallows Natural Boot Lateral Dunlop(for supracondylar #)
- 49. Advantages Non invasive Easy to apply Not expensive Disadvantages Wt. limitation Ischemia if too tight Stiffness and contractures formation
- 50. Complications -Compartment syndrome -Skin avulsion -Allergic rxn -Gangrene or ischemia -Joint stiffness - Hypostatic pneumonia
- 51. Gallows traction (Bryant) When is it used and in who? o Is a type of skin traction used in # of shaft of femur in children <3 years and weighing < 15kg
- 52. Indications (a) Orthopedic Hip dislocation # of pelvis, femur Disk prolapse Osteomyelitis Septic arthritis #/dislocation Sacrum
- 53. (b) Non- orthopedic Perineal or gluteal burn Perineal or gluteal abscesses Hernias- obturator and umbilical Rectal prolapse Contractures Scrotal swelling – congenital hydroceles Non-thrombosed hemorrhoids Spinal bifida
- 54. Advantages Easy to nurse/apply Non invasive Prevent decubitus ulcers Children don‘t find it distressing Not expensive Disadvantages Wt. limitation Ischemia if too tight Stiffness and contractures formation
- 55. Complications Skin avulsion Allergic rxn to strapping Compartment syndrome Joint stiffness Gangrene or ischemia to distal limb Hypostatic pneumonia