Downloaded 67 times
More Related Content
Similar to Fracture care
Fracture care
- 1. POP application course 18th December 2006 An Overview on Fractures Care Dr. Rashidi Ahmad MD USM, MMED USM, FADUSM Lecturer/Emergentist USM Health Campus
- 2. Objectives • To increasean awareness the importance of appropriate care of fracture • To increase understanding on fracture management • To gain more knowledge & skill – to make right decision & to perform the proper action
- 3. Outline • Understanding fractures •Describing fractures based on clinical presentations & radiological features • Principles of fracture management
- 4. Trauma patient isan injured person who requires timely diagnosis and treatment of actual or potential injuries by a multidisciplinary team of health care professionals, supported by the appropriate resources, to diminish or eliminate the risk of death or permanent disability. Europian Trauma Life Support
- 6. Fracture? • A fractureis a disruption in the integrity of a living bone involving injury to bone marrow, periosteum, and adjacent soft tissues.
- 7. How fractures occur? • Typical fractures • Pathologic fractures • Stress fractures
- 8.
- 9.
- 10. Life threatening fractures •Le Fort II/III fracture & bilateral mandible fracture with airway compromised • Upper cervical fracture & flail chest with impaired ventilation • Pelvic & open fractures with vascular injury/shock • Untreated multiple long bones fracture with fat embolism • Depressed skull fracture with extradural bleeding
- 11.
- 12. Pelvic injuries with intrabdominalinjury & shock
- 13. Limb threatening • Fractureswith Compartmental Syndrome @ Volkmann’s ischemia • Fractures with neurovascular injuries/ avascular necrosis • Open fractures with infection
- 14. Volkmann’s ischemic contracture Compartmental syndrome
- 15.
- 16.
- 17. Factors affecting fracturehealing • The energy transfer of the injury • The tissue response – Two bone ends in opposition or compressed – Micro-movement or no movement – BS (scaphoid, talus, femoral and humeral head) – NS – No infection • The patient • The method of treatment
- 18. Goals of fracturetreatment • Restore the patient to optimal functional state • Prevent fracture and soft-tissue complications • Get the fracture to heal, and in a position which will produce optimal functional recovery • Rehabilitate the patient as early as possible
- 19. Prehospital care • Firstaid principles • Preliminary splinting/sling of the injured extremity - reduces pain - reduces damage to nerve & vessels - reduces risk of conversion to open fracture - facilitates transportation & x-ray taking.
- 20. Principles Of Splinting • Apply dry sterile compression dressing to all open wounds
- 21. Principles Of Splinting •Incorporate one joint above and one joint below the fracture
- 22. Types Of Splints • Wooden Splints • Metal Wire / Frame Splints • Air Splints • Vacuum Splints • MAST suit
- 23.
- 24. Prehospital reduction • Prehospitalreduction of deformity – by advice of physician • Obvious fracture along the shaft of a long bone with a neurovascular deficit – longitudinal traction • Deformity near a joint – possibility of dislocation
- 25. Careful history • PreciseMOI • Listen carefully to the patient’s symptoms • Why? - Pain of fracture may be referred to another area - Specific x-ray view is indicated by proper history - Some injuries may not be radiologically apparent on the 1st day
- 26.
- 27.
- 31.
- 32. Chance # @lap seat belt #
- 33. Physical examination • Inspectionfor swelling, discoloration, deformity • Assessment of active & passive ROM of the joints proximal & distal to the injury • Palpation for tenderness • Verification of neurovascular status
- 34. Radiologic evaluation • X-rayis an important adjunct • Ordered based on Hx & PE • 2 views – AP & lateral • 2 joints – above & below the shaft fracture • In children with injury near the joint – bilateral x-rays for comparison • Repeat x-rays after 1 – 2 weeks to show callus in doubtful fractures
- 35. Describing fractures • Open versus closed • Location of the fracture • Orientation of the fracture line • Displacement & separation • Angulation • Shortening • Rotational deformity • Fracture – dislocation/subluxation • Salter fractures • Fragmentation • Soft tissue involvement
- 36.
- 37. Location of fracture Midshaft# Distal third # Intertrochanteric # Subcapital #
- 38. Head # Subtrochanteric # Neck # Near the head #
- 39. Supracondylar # Lateral condyle # Intercondylar #
- 40. Orientation of the fracture line
- 41. Torus # Greenstick #
- 42.
- 43.
- 44. Minimally displaced distalradius fracture Comminuted proximal- third femoral fracture with significant displacement
- 45. Angulation – amount& direction
- 46.
- 47.
- 48. Fracture - dislocation Bennet’s# dislocation Monteggia’s # Galeazzi’s #
- 49. Salter Harris classification I S = SLIPPED/separated II A = ABOVE III L = LOWER IV T = THROUGH/together V R = RAMMED/ruined
- 50.
- 51.
- 52.
- 53.
- 54.
- 55. Intraarticular fracure Rolando # Barton’s #
- 56. Fragmentation The Muller AOComprehensive Classification of Fractures - A multi-fragmentary fracture: several breaks (>2 fragments) in the bone - Wedge fractures: spiral (low energy) @ bending (high energy - The complex multi-fragmentary fracture: segmental fracture in which there is no contact between the proximal & distal fragments, no bone shortening. - Simple fractures are spiral, oblique, or transverse.
- 57. A multi-fragmentary fracture Wedgefractures
- 58. Soft tissue involvement Gustilo. Current Concepts: the management of open fractures. JBJS (1990); 72A; 299-304 • Minor / Grade I - small punctate wound <1 cm a/w low velocity trauma. Minimal soft tissue injury. No crushing. No comminution. • Moderate / Grade II – extensive wounds with relatively little soft tissue damage, and only moderate crushing or comminution. • Major / Grade III - wounds of moderate or massive size with considerable soft tissue injury and/or foreign body contamination: • III A - sufficient soft tissue to cover the fracture • III B - insufficient tissue to cover the fracture; also periosteal stripping and severe comminution • III C - arterial damage requiring repair. Degree of soft tissue damage not considered
- 59. Crush injury Degloving injury
- 60.
- 61. General management of patients with fracture • Life saving measures - Primary & secondary survey - Emergency orthopaedic involvement –Life saving –Complication saving
- 62. Cont… • Emergency orthopedicmanagement - Control of pain & swelling - Keep NBM if GA @ PCS is required - Reducing fracture deformity - Tetanus prophylaxis - Irrigation & debridement - Antibiotic prophylaxis • Conservative vs surgical management • Monitoring of fracture • Rehabilitation & Rx of complications
- 63. Emergency orthopaedic management • Life saving measures – Reducing a pelvic fracture in haemodynamically unstable patient – Applying pressure to reduce haemorrhage from open fracture • Complication saving – Early and complete diagnosis of the extent of injuries – Diagnosing and treating soft-tissue injuries
- 64. Diagnosing the soft tissue injury • Skin - Open fractures, degloving injuries and ischaemic necrosis • Muscles – Crush and compartment syndromes • Blood vessels – Vasospasm and arterial laceration • Nerves – Neurapraxias, axonotmesis, neurotmesis • Ligaments – Joint instability and dislocation
- 65. Treating the softtissue injury • All severe soft tissue injuries………require urgent treatment – Open fractures , Vascular injuries, Nerve injuries, Compartment syndromes, Fracture/dislocations • After the treatment of the soft tissue injury the fracture requires rigid fixation • A severe soft-tissue injury will delay fracture healing
- 66. Treating the fracture •Purpose: to reduce, hold & maintain the # in a suitable alignment • Does the fracture require reduction? Displaced? • Methods: CMR method by ACCROCHAGE and continuous traction (skin & skeletal traction) • What is acceptable # alignment? • Consider: age, site, weight bearing, shortening, angulation & rotation
- 67. Risk benefit Operative Non-operative Rehabilitation Rapid Slow Risk of joint stiffness Low Present Risk of malunion Low Present Risk of non-union Present Present Speed of healing Slow Rapid Risk of infection Present Low Cost ? ?
- 68. Treating the fracture •How are we going to hold the reduction? – Semi-rigid (Plaster) – Rigid (Internal fixation) • What treatment plan will we follow? – When can the patient load the injured limb? – When can the patient be allowed to move the joints? – How long will we have to immobilise the fracture for?
- 71. Indications for operativetreatment • General trend toward operative treatment last 30 yrs – Improved implants and antibiotic prophylaxis, use of closed and minimally invasive methods • Current absolute indications: – Polytrauma, displaced intra-articular fractures – Open #’s, #’s with vascular injury or compartment syndrome – Pathological #’s, Non-unions
- 72. Indications for operativetreatment • Current relative indications:- – Loss of position with closed method – Poor functional result with non-anatomical reduction – Displaced fractures with poor blood supply – Economic and medical indications
- 73. When is thefracture healed? • Clinically Upper limb Lower limb Adult 6-8 weeks 12-16 weeks Child 3-4 weeks 6-8 weeks • Radiologically – Bridging callus formation – Remodelling
- 74. Rehabilitation • Restoring thepatient as close to pre-injury functional level as possible • Approach needs to be:- –Pragmatic with realistic targets –Multidisciplinary: Physiotherapist, Occupational therapist, District nurse, GP, Social worker
- 75. Summary • Fractures area/w mortality & morbidity • Fractures care starts from the onset till fully recover • Primary survey + resuscitation are the PRIORITY • Do not underestimate the benefit of reassurance, pain management & splinting • Multidiscipline approach
- 76.
- 77. Dr. Rashidi Ahmad MD USM, MMED USM, FADUSM Pensyarah/Pakar Perubatan kecemasan & Trauma Jabatan perubatan Kecemasan Pusat Pengajian Sains Perubatan USM Kampus Kesihatan, Malaysia shidee_ahmad@yahoo.com +609 7663244