Principles of fractures and dislocations

Stress fracture
1. normal bone
3. repetitive stress
Pathological fracture
1. abnormal bone
  1. metastatic disease
  2. benign lesion
2. vs
3. physiological stress
Force
1. Direct
  1. break at point of impact (POI)
    1. + soft tissue damage
2. Indirect
  1. break away from POI
    1. +/- soft tissue damage
Mechanism of Injury
1. Spiral
  1. TORSION
    1. rotational force applied to a lever
      1. humerus
      2. femur
2. Short Oblique
  1. COMPRESSION
    1. greenstick
      1. children due to thickenss of periosteum
3. Butterfly
  1. BENDING
    1. Car accident
    2. Comminution
      1. e.g. vertebral comminution common when subject to
4. Transverse
  1. TENSION
How to describe a fracture
1. open or closed?
  1. open- antibiotics + cleaning of bone ends
2. bone(s)?
  1. location?
3. simple or comminuted?
4. complete or incomplete?
5. involvement of joint?
6. displaced or non displaced?
  1. displacement
    1. translation
      1. describe with reference to distal fragment (50%, 100%, or complete (off ended
    2. alignment
      1. angulation
    3. rotation
      1. twist
    4. length
      1. distraction
      2. separation
      3. overlap
7. traumatic, stress or pathological?
HEALING
1. INDIRECT
  1. In tubular bone in the absence of rigid fixaiton
    1. 1. Haemotoma formation
    2. 2. Inflammation and Cellular proliferation
    3. 3.Callus
      1. response to movement at the fracture site
      2. stabilise
    4. 4. Consolidation
    5. 5. Remodelling
2. DIRECT
  1. fracture immobilised
    1. example
      1. Fixed with metal plate
      2. impacted cancellous bone fracture
    2. fracture healing occurs directly between fragments WITHOUT CALLUS
3. HOW LONG?
  1. dependant on age, nutrition, general health, blood supply, type of fracture, fracture stability
4. promoted by physiological loading of bone (DONT IMMOBILISE)
CLINICAL FEATURES
1. LOOK
  1. swelling
  2. bruising
  3. deformity
  4. skin intact?
2. FEEL
  1. bony tenderness
  2. crepitus
    1. grating bone against bone
  3. pulses
  4. associated injuries
    1. tense compartment= compartment syndrome
3. MOVE
  1. maybe not if patient awake and conscious
    1. x-ray might be more appropriate
4. NEUROVASCULAR EXAM
  1. all nerves and vessels traversing the compartment
    1. at presentaiton AND after any intervention
IMAGING
1. X-RAY
  1. rule of 2's
    1. views, joints, limbs, injuries, occassions
2. ADVANCED IMAGING
  1. Technitium Bone Scan
    1. may be "cold" if performed within 48-72 hours of injury
  2. CT
    1. complex or interarticular fractures
    2. used to define bony anatomy
  3. MRI
    1. assessment of associate structures
      1. spinal cord, nerve root, ligament injuries
    2. soft tissue anatomy definition
TREATMENT
1. REDUCTION
  1. aim for adequate apposition and normal alignment
  2. closed
    1. + anasthesia
    2. distal limb pulled in line with bone
    3. fragments disengage and are repositioned
    4. alignment adjusted in each plane
    5. use
      1. most fractures in children
      2. for fractures that are stable after reduction
        can be fixated
      3. Unstable fractures can be reduced prior to internal fixation
  3. open
    1. operative reduction under direct vision
2. FRACTURE IMMOBILISATION
  1. casting/ FIXATION
  2. continuous traction
    1. typically children
  3. cast splintage
  4. funcitonal bracing
  5. internal fixation
    1. wires
    2. plates and screws
    3. intermedullary nails
  6. external fixation
  7. internal vs External
3. REHAB
COMPLICATIONS
1. EARLY
  1. vascular injury
  2. nerve injury
    1. shoulder- axillary
    2. humerus- radial
    3. humerus supracondylar- radial or median
    4. hip- sciatic
    5. knee- fibular
  3. compartment syndrome
    1. 5 P's
      1. pain out of proportion to injury and pain on passive stretch most important
  4. fracture blisters
  5. infection
2. LATE
  1. delayed union/ nonunion
    1. Injury factors
    2. treatment factors
    3. Pt factors e.g. smoking, NSAIDs, drinking
    4. Hypertrophic non-union: florid periosteal new bone formation, wants to heal- biology of healing okay just needs stability
    5. Atrophic non-union- no signs of healing, needs improved biology
  2. malunion
  3. avascular necrosis
    1. Femoral head, scaphoid, talus
  4. growth disturbance
  5. joint impairment
  6. pain syndromes

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Principles of fractures and dislocations

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	Created by Samantha Fredman almost 8 years ago