Principles of Fracture Treatment - 1.ppt

Principles of Fracture
Treatment
Dr. Mohammed Haidar
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‫الطالبية‬ ‫للخدمات‬ ‫االصدقاء‬ ‫مكتبة‬
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What is a fracture?
 Disruption of a bone’s normal structure
or “wholeness”
 Crack, break, or rupture in a bone
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Diagnosis
Clinical picture
Radiography
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Clinical Features of Fracture
 History of trauma
 Symptoms & signs :
1. Pain & tenderness 2. Swelling
3. Deformity 4. Crepitus
5. Loss of function 6. Abnormal move
7. Neurological and vascular injuries
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Physical Exam Basics
 Inspect and Palpate everything- start
with normal structures and move to
abnormal
 Range of motion in all planes
 Strength
 Sensation
 Reflexes
 Gait
 Stability
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Physical Exam Basics
1. Neurologic exam : Always document the
neurologic status. Some fractures are
associated with nerve injuries and knowing
the status of the nerve is critical
2. Vascular exam : Always check for pulses
distal to the fracture sight. Missed vascular
injuries can be devastating
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Pre-reading Musculoskeletal
Radiographs
1: Name, date, old films for comparison
2: What type of view(s)
3: Identify bone(s) & joint(s) demonstrated
4: Skeletal maturity (physes: growth plates)
5: Soft tissue swelling
6: Bones & joints (fractures & dislocations)
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Physical Exam
 NEVER trust someone else’s exam.
ALWAYS put your hands on the patient and
see for yourself.
 Always trust your exam - you WILL pick up
something that someone else has missed at
some point.
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OPEN AND CLOSED
FRACTURES
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Intro to Reading X-rays
 Reading a radiograph is essentially describing
the anatomy of a certain structure
 In order for it to be universal and
understandable for others, clarity and precision
are essential
 A fracture is described based on the findings of
the physical exam and a review of radiographs
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Reading X-rays
1. Say what it is - what anatomic structure
are you looking at and how many
different views are there
2. Regional Location - Diaphysis (rule of
1/3), Metaphysis, Epiphysis including
intra and extra - articular
3. Direction of the fracture line - Transverse,
Oblique, Spiral
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Reading X-rays
5. Condition of the bone - comminution
( 3 or more parts), Segmental (middle
fragment), Butterfly segment,
incomplete, avulsion, stress, impacted.
6. Deformity - Displacement (distal with
respect to proximal), angulation (varus,
valgus), rotation, shortening ( in cm’s),
distraction.
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Fracture Pattern
 Transverse
 Produced by a
distracting or
tensile force
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Fracture Pattern
 Spiral
 Produced by a
torsional force
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Fracture Pattern
 Produced by
pure bending
force
 Butterfly
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Fracture Pattern
 Comminuted
 Broken into
many pieces -
high energy with
combined forces
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Displacement
 Characterized by % of bone contact
on either view
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Angulation
 Distal fragment relative to proximal
Varus, Valgus, Anterior, Posterior
 Apex of angle formed by fragments
E.g., Apex Anterior, Apex Medial,
Apex Ulnar
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Location
 Commonly described in thirds of affected
bone :
 ie distal third of tibia
 ie junction of proximal and middle third
of femur
 If fractured at two levels describe as
segmental
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Location -Diaphysis
 Shaft portion of
bone
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Location - Metaphysis
 The ends of the
bone (if the fracture
goes into a joint it
is described as
intra - articular)
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Now All Together
 Transverse fracture of
the femur at the middle
third - distal third
junction with 100%
displacement and
varus (or apex lateral)
angulation
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What do you see?
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What do you see?
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What do you see?
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Mnemonic : OLD ACID
 O: Open vs. closed
 L: Location
 D: Degree (complete vs. incomplete)
 A: Articular extension
 C: Comminution / Pattern
 I: Intrinsic bone quality
 D: Displacement, angulation, rotation
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O: Open vs. Closed
 Open fracture
 AKA: “Compound fracture”
 A fracture in which bone
penetrates through skin;
 “Open to air”
 Some define this as a
fracture with any open
wound or soft tissue
laceration near the bony
fracture
 Closed fracture
 Fracture with intact
overlying skin
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L: Location
 Which bone?
 Thirds (long bones)
 Proximal, middle, distal
third
 Anatomic orientation
 E.g. proximal, distal,
medial, lateral, anterior,
posterior
 Anatomic landmarks
 E.g. head, neck, body /
shaft, base, condyle
 Segment (long bones)
 Epiphysis, metaphysis,
Diaphysis
Epiphysis
Metaphysis
Diaphysis
(Shaft)
Physis
Articular
Surface 30
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D: Degree of Fracture
 Complete
 Complete cortical
circumference involved
 Fragments are
completely separated
 Incomplete
 Not fractured all the way
through
 “Only one cortex”
involved
 e.g “Greenstick fracture”
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A: Articular Extension /
Involvement
 Intra - articular
fractures
 “Involves the articular
surface”
 Dislocation
 Loss of joint surface
/ articular congruity
 Fracture - dislocation
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C: Comminution / Pattern
 Transverse (Simple)
 Oblique (Simple)
 Spiral (Simple)
 Linear / longitudinal
 Segmental
 Comminuted
 Compression /
impacted
 Distraction / avulsion
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 Transverse (Simple)
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 Oblique (Simple)
 Spiral (Simple)
 Oblique in 2+ views
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 Linear / longitudinal / split
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 Segmental
 Bone broken in 2+ separate
places; Fx lines do not connect
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 Comminuted
 Broken, splintered, or crushed into >3 pieces
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 Compression
 Impacted
 (e.g. “Buckle / Torus”)
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 “Buckle / Torus”
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 Distracted
 Avulsion
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I: Intrinsic Bone Quality
Osteopenia
–
Decr’d density
Normal
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Normal
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Osteopetrosis
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 Osteopoikilosis
 Focal areas of
incr’d density
Normal
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D: Displacement, Angulation, Rotation
Displacement
Fragments shifted in
various directions relative
to each other
–
Convention :
–
describe displacement of
distal fragment relative to
proximal
Oblique tibial shaft Fx b/w
distal & middle thirds;
laterally displaced
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Angulation
Fx fragments are not
anatomically aligned
Convention :
Direction the apex is
pointing relative to
anatomical long axis of
the bone (e.g. apex
medial, apex valgus) R Tibial shaft Fx b/w
prox & middle thirds,
angulated apex lateral
(apex varus)46
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Angulation
Varus
Apex
lateral
Valgus
Apex medial
Parallel
No angulation
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Rotation
–
Fragments are rotated
relative to each other
Convention
:
–
Fragment is rotated
relative to the proximal
portion of the bone
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Rotation
Normal PA view of hip
–
Greater trochanter in
profile
PA view of rotated hip Fx
–
Greater trochanter
perpendicular to film
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Salter - Harris Fractures
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Other signs of fractures
 Periosteal reaction Callus / Osteosclerosis
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Other signs of fractures
 Fat pad sign / “Sail sign”
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Mechanism of Injury
Direct trauma
Indirect Trauma
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Direct trauma
 Tapping fractures
 Crushing fractures
 Penetrating fractures
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Indirect Trauma
 Traction or tension fractures
 angulation fractures
 Rotational fractures
 Compression fractures
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Principles of Fracture Repair
Fracture repair is a tissue regeneration
process rather than a healing process. The
injured bone is replaced by bone.
The process of repair varies according to :
-The type of bone involved.
-The amount of movement at the fracture.
-The closeness of the fracture surfaces.
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Principles of fractures
 Unfavorable factors
 Impairment of blood supply
 Infection
 Excessive movement
 Presence of tumor
 Synovial fluid in intraarticular Fx.
 Interposition of soft tissue
 Any form of Nicotine
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Definitive fracture treatment
The goal of fracture treatment is to obtain union
of the fracture in the most anatomical position
compatible with maximal functional return of the
extremity.
 Conservative
 Operative
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Principles of Treatment
 Treat the Patient, not only the fracture
 Restriction of movement
Prevention of displacement
Alleviation of pain
Promote soft-tissue healing
Try to allow free movement of the
unaffected parts
 Splint the fracture, not the entire limb
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Principles of Treatment
Methods of holding reduction :
Sustained traction
Cast splintage
Functional bracing
Internal fixation
External fixation
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Fixation Options
 Casts and Splints
 Appropriate for many fractures
especially hand and foot
fractures
 Adults typically will get plaster
splints initially transitioned to
fiberglass casts as swelling
decreases
 Kids typically will get
fiberglass casts
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CONSERVATIVE TREATMENT
Below Knee
Above Knee
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 Complications of cast splintage
1. Tight cast
2. Pressure sores
3. Skin abrasion or laceration
4. Loose cast
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Functional Bracing
 Prevents joint stiffness while still
permitting fracture splintage and
loading
 Most commonly for fractures of the
femur or tibia
 Since its not very rigid, it is usually
applied only when the fracture is
beginning to unite
 Comes out well on all four of the
basic requirements: “hold” “move”
“speed” “safe” 68
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Fixation Options
 Traction
 Useful in patients who are
too sick for surgery
 Useful to maintain
alignment until definitive
fixation
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 Traction by gravity
 Eg. Fractures of the humerus
 Balanced Traction
 Skin traction: adhesive strapping kept in place
by bandages
 Skeletal traction: stiff wire/pin inserted through
the bone distal to the fracture
Femur fracture managed with
skeletal traction and use of a
Steinmann pin in the distal femur.
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Operative
 ORIF ( open reduction internal fixation )
 External fixation
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Indications of ORIF
- Absolute indications
- Relative indications
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Absolute Indications for ORIF of fractures
 Unable to obtain an adequate reduction
 Displaced intra - articular fractures
 Certain types of displaced epiphyseal
fractures
 Major avulsion fractures where there is
loss of function of a joint or muscle group
 Non - unions
 Re - implantations of limbs or extremities
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Relative Indications for ORIF of fractures
 Delayed unions
 Multiple fractures to assist in care and
general management
 Unable to maintain a reduction
 Pathological fractures
 To assist in nursing care
 To reduce morbidity due to prolonged
immobilisation
 For fractures in which closed methods are
known to be ineffective
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Indications of ORIF
Questionable
 Fractures accompanying nerve of vessel
injury
 Open fractures
 Cosmetic considerations
 Economic considerations
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Open Operation
 Operative reduction is indicated :
1. When closed reduction fails
2. When there is a large articular fragment that needs
accurate positioning.
3. For avulsion fractures in which the fragments are
held apart by muscle pull.
4. When an operation is needed for associated
injuries.
5. When a fracture will anyhow need internal fixation
to hold it.
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Types of Internal Fixation
- Pin & wire fixation
- Screw fixation
- Plate & screws fixation
- Intra - medullary fixation
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Plate & screws fixation
Functional types :
 Compression plates
 Neutralization plates
 Buttress plates
 Bridge plates
 LC - DCP
 Liss plates
 Locking plates & screws
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Fixation Options
 Open Reduction and Internal
fixation with Plates and
screws
 Used for many fractures
especially those involving
joints.
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Intra - medullary fixation
 Centro - medullary
- Unlocked
- Interlocking(static – dynamic – double
locked)
 Condylocephalic
 Cephalomedullary
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Fixation Options
 Intramedullary Nails
 Treatment of choice for
most tibia and femur
fractures.
 Used in selected humerus
and forearm fractures.
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Internal Fixation
 “holds” :
Securely with precise reduction
 “movements” :
Can begin at once (no stiffness and edema)
 “speed”:
Patient can leave hospital as soon as wound
is healed, but full weight bearing is unsafe for
some time
 “safety” :
Biggest problem! SEPSIS!!!
 Risk depends on : the patient, the surgeon,
the facilities
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Indications for Internal Fixation
1. Fractures that cannot be reduced except by
operation
2. Fractures that are inherently unstable and
prone to re-displacement after reduction
3. Fractures that unite poorly and slowly
4. Pathological fractures
5. Multiple fractures
6. Fractures in patients who present severe
nursing difficulties
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1. Interfragmentary /Lag
Screws:
o Fixing small fragments
onto the main bone
2. Kirschner Wires
o Hold fragments together
where fracture healing is
predictably quick
3. Plates and screws
o Metaphyseal
fractures of
long bones
o Diaphyseal
fractures of
the radius and
ulna
4. Intramedullary nails
o Long bones
o Locking screws  resist
rotational forces
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 Joint Replacement
 Used in displaced femoral
neck fractures in geriatric
patients
 Allows for early ambulation
 Occasionally used in
geriatric pts with
comminuted shoulder or
elbow fractures
Fixation Options
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Complications of Internal Fixation
 Most are due to poor technique, equipment, or
operating conditions
 Infection
○ Iatrogenic infection is now the most
common cause of chronic osteomyelitis
 Non - union
○ Excessive stripping of the soft tissues
○ unnecessary damage to the blood supply in
the course of operative fixation
○ rigid fixation with a gap between the
fragments
 Implant failure
 Refracture
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Fixation Options
 External Fixation
 Used primarily in the
treatment of open
fractures and pelvis
fractures.
 Also useful as
temporary stabilization
prior to definitive
fixation.
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External Fixation
 Permits adjustment of length and angulation
 Some allow reduction of the fracture in all 3
planes.
 Especially applicable to the long bones and
the pelvis.
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- Severely comminuted and unstable fractures,
which can be held out to length until healing
commences.
- Fractures of the pelvis, which often cannot be
controlled quickly by any other method.
- Fractures associated with nerve or vessel
damage.
- Infected fractures, for which internal fixation
might not be suitable.
- Un-united fractures, where dead or sclerotic
fragments can be excised
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Indications
- Fractures associated with severe soft-tissue
damage where the wound can be left open for
inspection, dressing, or definitive coverage.
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Complications of External
Fixation
 Damage to soft-tissue structures
 Over - distraction
○ No contact between the fragments union
delayed / prevented
 Pin-track infection
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OPEN FRACTURES
 Initial Management
 At the scene of the
accident
 In the hospital
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Principles of Treatment of
Open Fractures
 All open fractures assumed to be
contaminated Prevent infection!
 The essentials :
 Prompt wound debridement
 Antibiotic prophylaxis
 Stabilization of the fracture
 Early definitive wound cover
 Repeated examination of the limb because
open fractures can also be associated with
compartment syndrome
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CONTRAINDICATIONS TO SURGICAL
REDUCTION AND STABILIZATION
1. Osteoporotic bone that is too fragile to allow
stabilization by internal or external fixation.
2. Soft tissues overlying the fracture or planned
surgical approach of such poor quality
because of scarring, burns , active infection,
or dermatitis .
3. Active infection or osteomyelitis
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CONT…
4. Fracture comminution to a degree that does not
allow successful reconstruction. This is most
commonly seen in severe intraarticular fractures.
5. General medical conditions contraindicated to
anesthesia are generally contraindications to the
surgical treatment of fractures.
6. Undisplaced or stable impacted fractures in
acceptable position do not require surgical
exposure or reduction.
7. Inadequate equipment, manpower, training, and
experience.
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Physical Therapy Treatment
 1) Physical therapy during immobilization
The aims during this period are:
 1. Reduce edema: It is very important to do this as early as
possible to prevent adhesion formation, and to decrease
pain.
 2. Assist the maintenance of the circulation to the area.
 3. Maintain muscle function by active or static muscle
contractions
 4. Maintain joint ROM
 5. Maintain function as allowed by the fracture and the
fixation.
 6. Teach the patient to use crutches, sticks, frames.
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CONT …
Assessment of the patient is essential in order to
decide on the treatment required. It is not always
necessary to treat a patient throughout this stage
provided that the patient can be taught to do his
own exercises. The patient must understand what is
required and be motivated to carry it out. The
physical therapist is responsible for monitoring the
patient through this stage. If it is necessary to
continue treatment this may be in the ward for an
inpatient but outpatients may either be treated in a
physiotherapy department or at home. Good
treatment at this stage may prevent some of the
problems that can occur when the fixation is
removed.
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Patient problems and physical therapy
techniques
 Swelling should be reduced by elevating the limb and
by active or static contractions of muscles thus
minimizing the formation of adhesions and consequent
stiff joints.
 Active exercises by static or isotonic muscle activity
will help to maintain a good blood supply to the soft
tissues and aid in the reduction of swelling and
prevent the formation of adhesions.
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CONT …
 Muscles that cannot produce movement of a joint because of
the fixation and do not work statically will waste very rapidly.
Isometric or isotonic contractions performed correctly and
repeated often enough will prevent excessive wasting.
 Encouraging functional activity when possible also helps
reduce the rehabilitation time after removal of fixation.
 Patients must understand the importance of their treatment
and physiotherapists must understand the problems and
requirements of each patient.
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CONT …
2) Physical therapy after the removal of fixation
 Assessment of the patient should be carried out to formulate a
plan of treatment.
Factors to be considered during evaluation :
 1. Although certain clinical features can be expected after a
particular fracture they will appear in different degrees in each
patient and in some cases may not be present.
 2. Every patient presents different problems apart from the
injury and these may relate to age, family, work, leisure and the
psychological reactions of the individual. These factors must
be taken into account in planning a program of treatment and
evaluating progress.
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CONT …
Aims of treatment :
1. To reduce any swelling.
2. To regain full range of joint movement.
3. To regain full muscle power.
4. To re-educate full function.
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CONT…
1) Swelling
 Swelling should not be a great problem if exercises and
general activities have been carried out during the
immobilization period. It may be a problem in the lower limb if
the muscles are very weak and there is a loss of joint range
as both factors will prevent an adequate pumping action on
the veins. Any edema must be reduced as quickly as possible
as this will hinder active movement and lead to the formation
of adhesions thus extending the rehabilitation period.
2) Range of joint movement
 Before attempting to regain any decreased range of
movement the reason for the loss of range should be
determined. It could be due to pain, edema, adhesions or
weak muscles. If there has been disruption of joint surfaces
this may prevent a return to full range.
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CONT …
3) Muscle power
 The building of muscle power will depend on gaining maximal
activity of the muscles and using them in all actions as prime
mover, antagonist, fixator and associated movements with
other muscle groups.
4) Full function
 In the majority of cases it should be possible to regain full
function but if not it is important to gain the optimum function .
Planning must also take into account the needs of the patient in
relation to home, work and leisure.
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RETURN TO WORK
In preparing a patient to return to work
 it is important to understand that the patient may
have to work all day and know what type of work is
involved-heavy laboring, industrial work on a
production bench requiring repetitive movements of
the hand or foot or both, or office work which can
require a variety of different activities.
 Similarly home and leisure activities must be
considered so that the patient is fully rehabilitated.
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Thank you
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Principles of Fracture Treatment - 1.ppt

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