MEQ-Orthopaedic fracture

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MEQ-Orthopaedic fracture

  1. 1. A 35 year old motorcyclist was involved in motor vehicle accident.On arrival, you noted he had multiple laceration wound with bone protrusion over his right leg.<br /><ul><li>What is your immediate management?
  2. 2. Triage the patient
  3. 3. Red-severe,chest pain
  4. 4. Yellow-
  5. 5. Green moderate,MVA,urti,stable vital sign
  6. 6. Assess the ABC
  7. 7. Airway-check for any airway obstruction (assess by talking to the patient,airway intact)
  8. 8. Stabilize the neck
  9. 9. Remove any foreign body/vomitus by using finger or suction
  10. 10. If there is still no clear airway,orotracheal tube can be inserted.
  11. 11. Breathing –inspect chest movement,SPO2 monitoring,breath sound,chest compression-tenderness positive,unconscious-immobility of the rib
  12. 12. despite clear airway,the ventilation is inadequate.
  13. 13. check for atelactasis,pneumothorax or a flail segment.
  14. 14. Pneumothoraz managed by chest decompression
  15. 15. Closed sucking chest wound
  16. 16. Chest tube insertion
  17. 17. Flail chest-endotracheal intubation and positive pressure airway
  18. 18. Circulation-check the pulse and BP,signs of shock,CRT,extremities
  19. 19. External haemorrhage by compression
  20. 20. Send FBC,BUSE and cross matching
  21. 21. Deformity-bruises,bleeding,
  22. 22. Presence of fracture over the right leg-immoblize
  23. 23. Bleeding stop by direct pressure
  24. 24. Level of consciousness
  25. 25. Secondary survey-head to toes examination
  26. 26. Then if stable,send for regional xray</li></ul>After stabilization of patient, with no life threatening injury, he was diagnosed to have open fracture grade 2 of mid shaft of tibia<br /><ul><li>How do you grade open fracture?
  27. 27. Gustillo Anderson classification
  28. 28. Grade Criteria 1Open fracture with wound less than 1 cm,clean wound,minimal soft tissue injury,clean wound2Open fracture with clean wound size about 1-10 cm, moderate comminution soft tissue injury3Wound more than 10 cm,crush tissue injuryA-adequate soft tissue coveringB-inadequate soft tissue covering,need flapC-with vascular injury
  29. 29. What is your management for the open fracture?
  30. 30. Assess the ABC
  31. 31. Rule out any life threatening injury
  32. 32. Head,neck,chest and pelvic injury
  33. 33. Tetanus and antibiotic prophylaxis
  34. 34. Administer tetanus immune globulin and anti tetanus toxoid to prevent tetanus
  35. 35. (if patient had given toxoid in 3 or more doses within the last 10 years, then the globulin is not required)
  36. 36. For Grade 1 and 2, 1st (eg. Cefazolin) or 2nd ( eg. Cefuroxime) generation of cephalosporin is required.
  37. 37. For Grade 3, an aminoglycoside (eg, gentamicin or tobramycin) and metronidazole are added to complement treatment. These antibiotics will cover the gram negative bacteria and anaerobes.
  38. 38. If the injury is a “farmyard injury" or water-type injury, penicillin should also be added to provide prophylaxis against Clostridium perfringens. (4 to 5 million units for every 6 hours)
  39. 39. Wound irrigation
  40. 40. Wound irrigation:
  41. 41. to dilute the contaminants and therefore reduce the bacteria load
  42. 42. The wound is diluted with copious amount of normal saline (sterile)
  43. 43. Basic rule:
  44. 44. - Grade I : 3L
  45. 45. - Grade II : 6L
  46. 46. - Grade III : 9L
  47. 47. Wound debridement
  48. 48. Surgical debridement is the process where the devitalized or dead tissues are removed from a wound bed.
  49. 49. Devitalized tissues (esp. the dead muscle) produces denatured protein which is a good nutrition for the bacteria
  50. 50. 4 C’ for muscle debridement:
  51. 51. - colour: red vs pale
  52. 52. - consistency: firm + elastic vs fragile + easily torn
  53. 53. - contractility: contract vs not contract
  54. 54. - capacity to bleed: bleeding easily vs no bleeding
  55. 55. Fracture stabilization
  56. 56. By using external fixator
  57. 57. Reduced risk of infection,
  58. 58. Maximum to 6 weeks only
  59. 59. More than than high risk of infection,pin tract loosening
  60. 60. Other indication for external fixator
  61. 61. Open fracture
  62. 62. Infected fracture
  63. 63. Bone lengthening
  64. 64. Open book pelvic facture
  65. 65. Neurovascular injury
  66. 66. Complication of external fixator
  67. 67. Pin tract infection
  68. 68. Pin tract loosening
  69. 69. Joint stiffness
  70. 70. Neurovascular injury
  71. 71. The aim of open fracture management is to convert the open fracture to close fracture.once the wound is healing with primary wound healing/secondary wound healing or tertiary then the management is as closed fracture.</li></ul>The patient was kept immobilized for 3 weeks. He was explained about his complication of having prolonged bed bound.<br /><ul><li>What is the complication of prolonged immobilization?
  72. 72. Deep vein thrombosis
  73. 73. Pressure sore
  74. 74. How would you prevent the complications?
  75. 75. Deep vein thrombosisPressure soreStocking net compressionElevation of lower limb+/- subcutaneous heparinRipple bedFrequent changing position every two hours
  76. 76. If there is pressure sores, how you managed it?
  77. 77. Local
  78. 78. Regular wound dressing
  79. 79. Remove the necrotic tissue,the pus and the slough,clean it with the povidone,chlorohexidine or normal saline,depeneds on the condition of the wound
  80. 80. Closed it with gauze etc
  81. 81. Systemic
  82. 82. Check the albumin level,the electrolyte and the blood supply to the affecting area.
  83. 83. Correct the abnormality
  84. 84. Supplement-multivatamin
  85. 85. Enough protein</li></ul>Patient was discharged with no complications.Few months later,he presented to your clinic with painless,mobile right leg.<br /><ul><li>What is your diagnosis?
  86. 86. Non union fracture
  87. 87. Complication of fractures</li></ul>Early LateNeurovascular injuryCompartment syndromeInfectionGas gangreneFat embolismDelayed unionMalunionNonunion avascular necrosisjoint instabilityosteoarthritis<br />On examination and radiological finding,he was diagnosed to have non union fracture.<br /><ul><li>How do you differentiate non union and delayed union?</li></ul>Non unionDelayed unionClinical featuresPainlessMobilePainfulNon mobileXraysNo signs of healing-no callus formationPresence of callus formation<br /><ul><li>What is the causes of non union (5I)
  88. 88. Infection
  89. 89. Inadequate blood supply
  90. 90. Interposition of soft tissues between the fragment
  91. 91. Inadequate immobilization
  92. 92. Interconnected two bones
  93. 93. What is your management for non union fracture?
  94. 94. Internal fixator and bone graft

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