REFERENCE -S DAS - google - Mercer's textbook of orthopaedics and trauma

1. CLINICAL DIAGNOSIS OF
FRACTURE
BY DR MANMATHA NAYAK
JUNIOR RESIDENT
GOVT MC COLLEGE,KOTTAYAM
KERALA

2. HISTORY
• 1) AGE-
• Epiphyseal separation – children
• Greenstick # - children
• Dislocation - adult
• Fractures - at any age
• 2) THE AMOUNT AND NATURE OF VIOLENCE
• How did it occur ??
• Mechanism of force ??

3. Green stick #

4. • How forceful was the injury ??
• * pathological #-violence is not severe enough to cause #
femoral neck #- senile osteoporosis
subtrochanteric #- pagets dz
femoral shaft # - 2ndary carcinoma

5. • Nature of violence –direct
• a) tapping in nature-transverse #
• b) crushing – communuted #
• -indirect
• a) twisting – spiral #
• b) bending force-transverse/ oblique #
• c)bending +axial compression-butterfly fragment
• d)twisting+angulation+axial compression-short oblique #
• - muscular

7. • Muscle contracts against resistance may lead to #
• Ex- patella,olecranon ,lesser trochanter of the femur
• 3) PAIN- in # pain is felt only during movement of # site
• Pain -least in impacted and greenstick #
• -unbearable and constant in dislocation
• 4) LOSS OF FUNCTION-
• Unable to move the fractured limb
• He cannt put weight on it
• In Dislocation –unable to move the joint even slightly

8. • 5)DEFORMITY OR SWELLING
• # and dislocation often presents with swelling or deformity

9. LOCAL EXAMINATION
• The injured side should always be compared with sound side

10. INSPECTION
• 1)ABNORMAL SWELLING AND DEFORMITY-
• Deformity- is due to displaced # fragments
• Swelling- is dt hematoma
• 2) ATTITUDE-
• In certain # patients adopt particular attitude
• # NOF – limb externaly rotated
• Posterior dislocation of hip- thigh is in flexion ,adduction and internal
rotation

11. • 3)SHORTENING-
• Dt overlapping of fracture fragments
• 4) OVERLYING SKIN-
• Skin intact or not???
• Intact- closed #
• Not intact -# hematoma communicating to outside-Open#
• Edema ,bullae,blebs are quite common dt interference with venous
return
• Echymosis also appears within a few days after a # or dislocation

12. PALPATION
• 1)TENDERNESS-
• Local bony tenderness is valuable sign of #
• Elicited with relation with bone not with the soft tissue
• All throughout the length bone is palpated

13. • 2)BONY IRREGULARITY-
• Whole bone is palpated
• To look for any irregularity-such as sharp elevation,gap etc.
• Definite sign of #
• 3) ABNORMAL MOVEMENT-
• This is also definite sign of #
• Can be elicited by moving one fragment against other

14. • 4) CREPITUS-
• It is a sensation of grating which may be felt or heard ,when the bone
ends are move against each other
• Other condition which produce crepitus-
• Ex Hematoma,surgical emphysema,gas gangrene,oa ,tenosynovitis
and charcots joint

15. • 5) PAIN ELICITED BY MANIPULATING FROM DISTANCE-
• a) by rotating – in case of humerus or femur
• b) by squeezing-both bones of leg and forearm
• c ) by axial pressure in the line of bone-in metacarpal and metatarsal
#
• 6) ABSENCE OF TRANSMITTED MOVEMENTS-
• Assessed by rotating humerus and femur with flexed elbow or knee
respectively by palpating the tubercle of humerus or trochanter of
the femur

16. • 7) SWELLING-
• Characteristic should be noted -wheather bony swelling swelling
arises from neighbouring joint ??

17. MEASUREMENT
• 1)LONGITUDINAL-
• To know if there is any shortening
• 2)CIRCUMFERENTIAL-
• To now if there is any wasting dt injury
* While taking measurement the sound limb should be kept in the
same position as the affected limb
* Always good to measure the healthy limb first
* measurement should be marked with skin pencil before the use of
measuring tape

18. Longitudinal measurement

20. * Measurement should be at the same level in both the limbs in case of
circumferencial measurement

21. MOVEMENTS
• Both active and passive movement should be tested
• Good – no bony or joint injury
• Stiffness of the joint is a complication of the # and may be dt-
intraarticular and periarticular adhesions,myositits
ossification,sudecks osteodystrophy

22. INVESTIGATIONS
• A) X RAYS-
• minimum 2 view
• Ap /lateral
• Some time oblique and other special views
• B)CT SCAN –
• C)MRI-too expensive

23. GENERAL PRINCIPLES OF
MANAGEMENT OF FRACTURE

24. GOAL OF FRACTURE M/M
• Restore the anatomy back to its normal or as near to normal as
possible
• There should not be any functional disability to the pt following the
treatment of fractures

25. MANGEMENT OF SIMPLE FRACTURES
• can be managed with conservative or operative methods
• A) CONSERVATIVE METHODS
• For undisplaced #,incomplete #,impacted #
• Cuff and collar sling- for upper limb #
• Strapping for # clavicle,finger #,toe #
• Pop slab
• NSAIDS

26. Cuff and collar sling

27. Buddy strapping

28. • B)OPERATIVE –
• For displaced #
• CLOSED REDUCTION OR OPEN REDUCTION
• 1)Closed reduction-
• Adopted usually for simple frctures
• Technique followed is traction and counter traction method
• Continous traction is used for reduction of fracture
• Ex gallows traction for # sof in children,skeletal traction for adult SOF

29. Gallows traction

30. Skeletal traction

31. • Once the # is reduce it has to be retained in position till # unites by
pop,continuous traction ,or by using functional brace
• Rehabilation is by physiotherapy and exercises once the fracture
unitess
• 2)Open reduction
• Indiacated once the conservative m/m fail or when there are specific
indication

32. • INDICATIONS-
• Absolute- failed closed reduction
- displaced intraarticular #
-type 3 and 4 epiphyseal injury
- major avulsion#
- nonunion
• Relative -multiple # - for better nursing care
-delayed union - to avoid prolong bed rest
- loss of reduction

33. • METHODS OF OPEN REDUCTION-
• After the exposure the # is redued by direct or
• indirect methods the # is reduced without exposing by positioning
and traction over the fracture table s,skeletal traction etc
• PRINCIPLES OF OPEN REDUCTION( by lambotte )
• Exposure-the # is adequately exposed through a proper approach
• Reduction of # fragments under direct vision
• Temporary stabilization-of the # using k wire done first if necessary

34. • Definitive stabilization using palte ,screws or intramedullary nails ,k
wire ,ss wire etc done later,
• Rehabilation process is same as closed mm of fractures
• CONTRAINDICATION OF OR-
- Infection
-small fragments
- soft tissue damage
- poor general and medical condition

36. OPEN FRACTURES
• Orthopaedic emergency
CLASSIFICATION-
1)GUSTILO AND ANDERSONS
TYPE 1- wound <1 cm
TYPE II- wound 1- 10 cm, soft tissue normal
TYPE III-wound > 10 cm
soft tissue are devitalized and contaminated

37. Type 1

38. TYPE II

39. TYPE IIIA

40. TYPE IIIB

41. TYPE IIIC

42. • TYPE IIIA- with extensive soft tissue injury but with adequate soft
tissue to cover the # bone
• TYPE IIIB-extensive soft tissue damage and loss
- bone cannot be covered
• TYPE IIIC-with vascular injuries
• 2)TSCHERNE CLASIIFICATION
• 3)AO CLASSIFICATION

43. • APPROACH IN OPEN FRACTURES-
• General examination-vitals
• Examination of other system-
• Then examination of open #

44. AIMS OF M/M
• To convert the contaminated wound into clean wound and thus help
to convert an open # into a closed one
• To establish union in good position
• To prevent infection
APPROACH
• Stabilise the vital and general condition pt first
• Keep the wound covered with proper sterile bandages until the
patient is ready for surgery
• Open # are surgical emergency and sx to be done once the pt is fit

45. • DEBRIDEMENT-consists of following steps
• Exploration of wound
• Excision of all non viable tissue
CIrteria to assess tissue viability
color –pink –pale
consistency-firm-flabby
capacity to bleed-+,-
contractility-+,-

46. • Evacuation-of foreign bodies like dirt,glass,stones,pebbles etc.
• Fb are source of infection may invite aforeign body reaction
• Hence they hav to be removed by a through irrigation
• External fixators are used for fracture fixation after debridement
- help to stabilize # fragments
- allow daily wound inspection and dressings
- permits procedure like ssg for wound covering
- allow soft tissue healing and early mobilisation

47. EXTERNAL FIXATOR

48. • ANTIBIOTICS ,ANALGESICS,TETANUS PROPHYLAXIS
• External fixation can be used as definitive treatment of fracture,or can
be removed after 2-3 weeks if soft tissue is healed for definitve
procedure like plate ,screw ,interlocking nail etc.

49. APPROACH TO A POLYTRAUMA CASE
Initial evaluation
• A-AIRWay
• B-breathing
• C-circulation
• D- disability
• E-Exposure
• F-fracture examination
• G-go back to the beginning for a2ndary survey
• H-help

50. THANK U……