This document provides an overview of orthopaedic trauma and fracture management. It defines the golden hour of trauma and describes the ATLS protocol. It discusses the primary and secondary surveys for trauma patients. Key aspects of fracture assessment and basic fracture mechanics are reviewed. The stages of fracture healing and factors affecting healing are outlined. Methods for maintaining fracture reduction both externally (casts, traction, external fixators) and internally (wires, pins, plates, nails, screws) are summarized.

1. Orthopaedic Trauma
Mr Hiren Divecha
ST3 T&O
19/1/2011

3. Definitions

4. Trauma & Basic Management

5. 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

7. 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

8. ATLS
• Airway (+ cervical spine
immobilisation)
• Breathing (+ high flow O2)
• Circulation
• Disability
• Exposure

9. 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

10. 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

11. 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

12. • 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)

13. 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

14. Urgent Skeletal Issues
• Irrigation and Debridement of open fractures
• Reduction of dislocations
• Splinting of fractures
• Compartment syndromes

15. Fracture Basics

16. Basic Biomechanics
• Bending
• Axial Loading
– Tension
– Compression
• Torsion
Bending Compression Torsion

17. 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

18. Fracture Mechanics

20. 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

21. 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

22. Fracture Pattern
• Transverse
• Produced by a
distracting or tensile
force

23. Fracture Pattern
• Spiral
• Produced by a twisting/
torsional force

24. Fracture Pattern
• Butterfly
• Produced by pure
bending force

25. Fracture Pattern
• Comminuted
• Multifragmentary
• High energy transfer!!

26. Location-Diaphysis
• Shaft portion of bone

27. Location-Metaphysis
• The ends of the bone (if
the fracture goes into a
joint it is described as
intra- articular)

28. What do you see?

29. What do you see?

30. What do you see?

31. What do you see?

32. Fracture Management

33. 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

34. Inflammatory/ Hematoma Phase (1st)
• Up to 1 week
• Acute inflammation
• Hematoma formation
(48-72 hours)
• Inflammatory cytokines
• Fibroblasts –
granulation tissue
• Angiogenesis

35. Soft Callus Phase(2nd)
• 1 week – 1 month
• Chondroblasts +
fibroblasts
• Fibrous tissue +
cartilage + woven bone

36. Hard Callus Phase (3rd)
• 1 – 4 months
• Soft callus resorbed and
replaced by osteoid
from osteoblasts
• Osteoid mineralised
(hydroxyapatite)
• United, solid, pain free

37. 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)

38. 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

40. 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)

41. Treatment of fractures
• Reduce
• Maintain reduction (+ hold until union)
• Rehabilitate – restore function
• Prevent or treat complications

42. Maintain reduction
• How?
– External method
• POP (+ equivalents), traction, external fixator
– Internal method
• Wires, pins, plates, nails, screws

43. 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

44. 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

45. 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

46. Maintain reduction – external method
• Skeletal traction
– Requires invasive
procedure for longer
term traction requiring
heavier weights
– Complications
associated with pin
insertion eg. infection

47. 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

48. 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)

49. Maintain reduction – internal method
• Stainless steel, titanium, cobalt
• Complications
– Infection
– Non-union
– Implant failure
– Re-fracture

50. Maintain reduction – internal method
• Wires
– Can be used in conjunction
with other forms of internal
fixation
– Used to treat fractures of
small bones

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. Thanks for listening !
Any questions