Orthopaedic Trauma - The Basics


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Overview of trauma management and fracture healing/classification/management

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Orthopaedic Trauma - The Basics

  1. 1. Orthopaedic Trauma Mr Hiren Divecha ST3 T&O 19/1/2011
  2. 2. Definitions
  3. 3. Trauma & Basic Management
  4. 4. Trauma• Golden Hour of Trauma – Rapid transport of a severely injured patient to a trauma center for definitive care – Initial treatment has a significantly higher chance for survival during this period
  5. 5. Trauma Evaluation• ATLS – Advanced Trauma and Life Support – A standardized protocol for the evaluation and treatment of victims of trauma – Developed by a Nebraska orthopaedic surgeon who was involved in a trauma and was not satisfied with the lack of a protocol for such patients
  6. 6. ATLS• Airway (+ cervical spine immobilisation)• Breathing (+ high flow O2)• Circulation• Disability• Exposure
  7. 7. Primary Survey• Rapid assessment of ABC’s and addressing life threatening problems – establishing airway and ventilation, placing chest tubes, control active hemorrhage• Place large bore IV’s and begin fluid replacement for patients in shock• Trauma x-rays – chest, pelvis and lateral C-Spine
  8. 8. Secondary Survey• Assessing entire patient for other non-life threatening injuries.• Orthopaedic assessment of skeleton – splint fractures – reduce dislocations – evaluate distal pulses and peripheral nerve function• Obtain Xray or CT of affected areas when pt is stable
  9. 9. Trauma Assessment• History  Mechanism of Injury• Palpation• Note swelling, Lacerations• Painful ROM• Crepitus- that grating feeling when two bone ends rub against each other• Abnormal Motion- ie the tibia bends in the middle• Check pulses, sensory exam, and motor testing if possible
  10. 10. • Assess for lacerations that communicate with the fracture – Closed Fracture= intact skin over fracture – Open Fracture= laceration communicating with fracture (often referred to as a compound fracture by lay persons)
  11. 11. Emergency Skeletal Issues• Hemorrhage control from Pelvis Fractures in pt with labile blood pressure (shock) – Close pelvic volume• Hemorrhage control from open fractures – Direct pressure• Restore pulses by realigning fractures and dislocations
  12. 12. Urgent Skeletal Issues• Irrigation and Debridement of open fractures• Reduction of dislocations• Splinting of fractures• Compartment syndromes
  13. 13. Fracture Basics
  14. 14. Basic Biomechanics • Bending • Axial Loading – Tension – Compression • TorsionBending Compression Torsion
  15. 15. Describing The Fracture• Mechanism of injury – traumatic, pathological, stress• Anatomical site – bone and location in bone• Fracture geometry/ type• Displacement – three planes of angulation – translation – shortening – rotation• Articular involvement – Involving joint – Fracture – dislocation• Soft tissue injury – Closed vs open – nerves, vessels, tendons, tissue loss
  16. 16. Fracture Mechanics
  17. 17. Reading X-rays• Say what it is – what anatomic structure are you looking at and how many different views are there• Regional Location – Epiphysis, metaphysis – Diaphysis (rule of 1/3rds) – Intra/extra-articular• Fracture geometry/ type – Transverse, Oblique, Spiral
  18. 18. Reading X-rays• Condition of the bone – Comminution (3 or more parts) – Segmental (middle fragment) – Butterfly segment• Deformity – Angulation (varus/valgus, anterior/posterior) – Translation – Rotation – Shortening/ distraction
  19. 19. Fracture Pattern• Transverse• Produced by a distracting or tensile force
  20. 20. Fracture Pattern• Spiral• Produced by a twisting/ torsional force
  21. 21. Fracture Pattern• Butterfly• Produced by pure bending force
  22. 22. Fracture Pattern• Comminuted• Multifragmentary• High energy transfer!!
  23. 23. Location-Diaphysis• Shaft portion of bone
  24. 24. Location-Metaphysis• The ends of the bone (if the fracture goes into a joint it is described as intra- articular)
  25. 25. What do you see?
  26. 26. What do you see?
  27. 27. What do you see?
  28. 28. What do you see?
  29. 29. Fracture Management
  30. 30. Goals of fracture treatment• Restore patient to optimal functional state• Prevent fracture and soft tissue complications• Get fracture to heal and in satisfactory position for optimal functional recovery• Rehabilitate as early as possible
  31. 31. Inflammatory/ Hematoma Phase (1st)• Up to 1 week• Acute inflammation• Hematoma formation (48-72 hours)• Inflammatory cytokines• Fibroblasts – granulation tissue• Angiogenesis
  32. 32. Soft Callus Phase(2nd)• 1 week – 1 month• Chondroblasts + fibroblasts• Fibrous tissue + cartilage + woven bone
  33. 33. Hard Callus Phase (3rd)• 1 – 4 months• Soft callus resorbed and replaced by osteoid from osteoblasts• Osteoid mineralised (hydroxyapatite)• United, solid, pain free
  34. 34. Remodeling Phase (4th)• Up to several years• Hard callus remodels to woven bone then lamellar bone• Osteoclasts/ osteoblasts• Medullary canal reforms• Remodels according to stresses/ loading – Wolff’s Law (1892)
  35. 35. Factors affecting fracture healing• Energy transfer of the injury• The tissue response – Two bone ends in apposition or compressed – Micro-movement or no movement – Blood supply – Infection• The patient• The method of treatment
  36. 36. Diagnosing the bone injury• History – Mechanism – If pain preceded trauma ?pathological• Examination – General - ABCDE – Local – the fracture, swelling, tenderness (crepitus?), abnormal posture, skin wound – Distal – • Circulation – vascular injury? • Neurological – sensory and motor deficit?• Investigation - Imaging – 2 Views (AP/Lateral) – 2 Joints (above and below injury) – 2 Sides (for comparison, mainly in children) – 2 Times (before and after treatment)
  37. 37. Treatment of fractures• Reduce• Maintain reduction (+ hold until union)• Rehabilitate – restore function• Prevent or treat complications
  38. 38. Maintain reduction• How? – External method • POP (+ equivalents), traction, external fixator – Internal method • Wires, pins, plates, nails, screws
  39. 39. Maintain reduction – external method• POP• Mould with palms – Adv – cheap,easy to use, convenient, can be moulded – Disadv – susceptibility to damage (disintegrates when wet), up to 48hrs to dry
  40. 40. Maintain reduction – external method• Resin cast• Adv – lighter and stronger – sets in 5-10mins – max strength in 30mins• Disadv – Cost – more difficult to apply/remove – more rigid with greater risk of complications eg. swelling and pressure necrosis
  41. 41. Maintain reduction – external method• Skin traction – Temporary measure when operative fixation not available for awhile – Skin can be injured if applied for long periods of time
  42. 42. Maintain reduction – external method• Skeletal traction – Requires invasive procedure for longer term traction requiring heavier weights – Complications associated with pin insertion eg. infection
  43. 43. Maintain reduction – external method• External fixator• Indications – Fractures associated with severe soft tissue – Fracture associated with N/V damage – Severely comminuted and unstable fracture – Unstable pelvic fracture – Infected fracture• Complications – Pin track infection – Delayed union
  44. 44. Maintain reduction – internal method• Advantages – Shorter hospital stay – Enables individuals to return to fxn earlier – Reduces incidence of non and mal-union• Indications – Fractures that need operative fixation – Inherently unstable fractures prone to re-displacement after reduction (eg. mid-shaft femoral fractures) – Pathological fracture – Polytrauma (minimise ARDS) – Patients with nursing difficulties (paraplegics, v. elderly, multiple trauma)
  45. 45. Maintain reduction – internal method• Stainless steel, titanium, cobalt• Complications – Infection – Non-union – Implant failure – Re-fracture
  46. 46. Maintain reduction – internal method• Wires – Can be used in conjunction with other forms of internal fixation – Used to treat fractures of small bones
  47. 47. Maintain reduction – internal method• Pins – Usually used in pieces of bone that are too small to be fixed with screws – Usually removed after a certain period of time, but may be left in permanently for some fractures
  48. 48. Maintain reduction – internal method• Plates – Extend along the bone and screwed in place – May be left in place or removed (in selected cases) after healing is complete
  49. 49. Maintain reduction – internal method• Nail or rods – Held in place by screws until the fracture is healed – May be left in the bone after healing is completed
  50. 50. Maintain reduction – internal method• Screws – Most commonly used implant – Can be used alone to hold a fracture, as well as with plates, nails or rods – May be designed for a specific fracture – May be left in place or removed after the bone heals
  51. 51. Maintain reduction – how long?• Judge each case on its own merits• X-ray in POP for position; out of POP to clinically assess state of healing• Sticky – “Deformable but not displaceable”• Union (weeks) – Incomplete repair; Part moves as one; Local tenderness; Local pain on stress; See fracture line on-x-ray• Consolidation (months) – Complete repair; No external protection needed; Upper limb 6/52; Lower limb 12/52; Half for child; Double for transverse fractures
  52. 52. Complications of fractures• Early • Late – Visceral/ vascular/ nerve injury – Mal-union – Haemarthrosis – Delayed union – Infection – Non-union – Fat embolism – Tendon rupture – Compartment syndrome – Myositis ossificans – Osteonecrosis – Complex regional pain syndrome – Osteoarthritis and joint stiffness
  53. 53. Thanks for listening ! Any questions