Tbl 1 orthopedic trauma
This presentation is the property of its rightful owner.
Sponsored Links
1 / 97

TBL 1: Orthopedic Trauma PowerPoint PPT Presentation


  • 147 Views
  • Uploaded on
  • Presentation posted in: General

TBL 1: Orthopedic Trauma. Husna, Izzati, Ili Safia, Aqilah & Safiyyah. TBL Trigger. A 24 year old man was involved in a road traffic accident. He was a pedestrian when a motorcycle knocked him down when he was crossing the road.

Download Presentation

TBL 1: Orthopedic Trauma

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Tbl 1 orthopedic trauma

TBL 1: Orthopedic Trauma

Husna, Izzati, Ili Safia, Aqilah & Safiyyah


Tbl trigger

TBL Trigger

  • A 24 year old man was involved in a road traffic accident.

  • He was a pedestrian when a motorcycle knocked him down when he was crossing the road.

  • Following that incident, he complained of pain of the left leg and was unable to bear weight on his left lower limb.


Tbl 1 orthopedic trauma

  • In A&E, physical examination was performed:

    • Revealed swollen, tender and deformed proximal region of the left leg.

    • No limb threatening injury noted.

    • No wound overlying the deformed region.

  • An X-ray of the left leg done reported transverse fracture proximal of the left fibula.


Tbl 1 orthopedic trauma

  • He was admitted to the ward:

    • The left leg was elevated on the Bohler Braun frame awaiting for the swelling to subside and to observe for Compartment syndrome.

    • He was told the fracture is best treated with internal fixation but he opted for conservative treatment.

    • Full leg POP cast was applied after 3 days of admission.


Tbl 1 orthopedic trauma

  • Follow up visit (6 weeks post-trauma):

    • X ray was done and it showed no healing signs.

    • The earlier cast was removed and changed to patellar tendon bearing cast for another six weeks.

  • Follow up visit (12 weeks post-trauma):

    • Revealed mobility to the fracture site –painless.

    • He was told to have problem with the fracture healing and needs surgical treatment.


Learning issues

Learning Issues

  • Anatomy of the Leg.

  • Fracture – Definition, Classification and Patterns.

  • Principle of Fracture Management.

  • Acute Complications of Fracture.

  • Process of Fracture Healing.

  • Late Complications of Fracture.

  • Non Union Fracture – Definition, Classification and Management.


Anatomy of the leg

Anatomy of the Leg


The leg

The Leg

  • Bones

  • Muscles

    • Compartments

  • Blood Supply

  • Nerve Supply


I bones

i. Bones


Ii muscles and compartments

ii. Muscles and compartments

Anterior

Tibia

Lateral

TA

EDL

ELH

PL & B

Tibialis post.

FDL

FHL

Fibula

Soleus

gastrocnemius

Deep Posterior

Superficial Posterior


Leg compartments

Leg compartments


Tbl 1 orthopedic trauma

Anterior compartment

Walls :

  • Interosseous membrane

  • Tibia

  • Fibula

    Contents :

  • Extensor muscles of the toes

  • Anterior tibial artery

  • Deep peroneal nerve

  • Most susceptible to compartment syndrome.


Tbl 1 orthopedic trauma

Lateral compartment

Walls :

  • Fibula

  • Intermuscular septums

    Contents:

  • Peroneal muscles

  • Superficial peroneal nerve


Tbl 1 orthopedic trauma

Superficial Posterior compartment

Walls:

  • Transverse intermuscular septum

    Contents :

  • Gastrocnemius

  • Soleus muscles


  • Tbl 1 orthopedic trauma

    Deep Posterior compartment

    Walls :

    • Transverse intermuscular septum

    • Interosseous membrane

      Contents:

    • Flexor muscles of the foot

    • Tibial artery

    • Tibial nerve


    Summary

    Summary


    Nerve and arteries

    Nerve and Arteries


    Fracture definition classification and patterns

    Fracture – Definition, Classification and Patterns


    Definition of fracture

    Definition of Fracture

    A break in the structural continuity of bone.

    - Apley’s System of Orthopedics & Fractures, 8th Edition


    I open compound fracture

    i. Open (Compound) Fracture

    • Breakage in the bone that breaches the skin or one of the body cavities.

    • Usually due to high-energy injuries e.g. MVA, falls, sports injuries.

    • Liable to contamination and infection hence require immediate treatment and surgery to clean the area.


    Tbl 1 orthopedic trauma

    Open Fracture

    Fracture of tibia-fibula with soft-tissue injury


    Ii closed simple fracture

    ii. Closed (Simple) Fracture

    • Breakage in the bone with the overlying skin still intact.

    • 3 types:

      • Compression fracture

        • Occurs when 2 or more bones are compressed against each other – commonly in the spine bone.

        • Due to falling in a standing or sitting position, advanced osteoporosis.


    Tbl 1 orthopedic trauma

    • Avulsion fracture

      • Occurs when a piece of bone is broken off by a sudden forceful contraction of a muscle.

      • Common in young athletes.

    • Impacted fracture

      • Occurs when pressure is applied to both ends of one bone causing it to split into fragments that collide with each other.

      • Similar to compression fracture, only it is within one bone.

      • Common in falls and MVA.

    **View video http://video.about.com/orthopedics/Fractures-2.htm for better understanding.


    Tbl 1 orthopedic trauma

    Closed fracture


    Tbl 1 orthopedic trauma

    Compression fracture of the spine


    Tbl 1 orthopedic trauma

    Avulsion fracture of the phalanges

    Impacted fracture of the femur

    Impacted fracture of the tibia


    Iii pathological fracture

    iii. Pathological Fracture

    • Breakage of bone in an area that is weakened by another disease process either by:

      • Changing the structure i.e. osteoporosis, Paget’s disease.

      • Presence of lytic lesion i.e. bone cyst or metastasis.

      • Infection.

    • Usually occur during normal daily activities  bone unable to withstand even the normal stresses.


    Tbl 1 orthopedic trauma

    Multiple myeloma of humerus with pathological fracture

    Bone cyst resulting in pathological fracture in the neck of femur


    Iv stress fracture

    iv. Stress Fracture

    • Usually fractures are caused by acute, high force to the bone i.e. MVA, fall.

    • In Stress facture, the force applied is much lower but it happens repetitively for a long period of time.

    • Rarely occur in the upper extremity because weight bearing is by lower extremity – common site shin and foot.


    Tbl 1 orthopedic trauma

    • Contributing factors:

      • Athletes

        • High demand of activity repetitively.

      • Diet abnormalities

        • Poor nutrition e.g. in aneroxia, bulimia.

      • Menstrual irregularities

        • Irregular cycles/amenorrhea signify lack of estrogen which results in lower bone density.

        • Common in female athletes.


    Tbl 1 orthopedic trauma

    Stress fractures of the tibia-fibula


    I incomplete fracture

    i. Incomplete Fracture


    I complete fracture

    i. Complete Fracture


    Tbl 1 orthopedic trauma

    **View video http://video.about.com/orthopedics/Fractures-1.htmfor better understanding.


    Principles of fracture management

    Principles of Fracture Management


    First general resuscitation

    FIRST  GENERAL RESUSCITATION


    At the hospital

    At the Hospital

    • Examine HEAD  TOE

    • Level of consciousness  GCS

    • Remember:


    Fractures principles of treatment

    Fractures – Principles of Treatment

    • Manipulation – improve position of fragments.

    • Splintage – hold.

      WHILST:

    • Preserving the joint movement and function – exercise and weight bearing.


    Tbl 1 orthopedic trauma

    Closed Fractures


    1 closed fractures reduce aim adequate apposition and normal alignment of the bone fragments

    1. Closed Fractures – REDUCEAim  adequate apposition and normal alignment of the bone fragments

    Methods:


    2 closed fractures hold aim splint fracture

    2. Closed Fractures – HOLD Aim  splint fracture

    Methods:


    Tbl 1 orthopedic trauma

    Transfixing pin passes to:1. Proximal tibia – hip, thigh and knee injuries2. Distal tibia/calcaneum – tibial fractures

    Balanced skin traction

    Braun’s frame


    3 closed fractures exercise aim restore function

    3. Closed Fractures – EXERCISEAim  restore function

    • Prevention of edema

    • Active movement/exercise – stimulate circulation, prevents soft tissue adhesion and promote healing

    • Assisted movement – restore muscle power

    • Functional activity – guide patient in performing normal daily acitivities


    Open fractures

    Open Fractures


    Gustilo s classification

    Gustilo’s Classification


    Principles of treatment

    Principles of Treatment


    Tbl 1 orthopedic trauma

    Debridement

    Skin graft

    Stabilization


    Acute complications of fracture

    Acute Complications of Fracture


    Complications of fracture

    Complications of Fracture


    I underlying visceral injury

    i. Underlying Visceral Injury

    • Often in fractures around the trunk.

      • Rib fractures  penetration of lung  life-threatening pneumothorax .

      • Pelvic fractures  rupture of bladder or urethra.

    • Require emergency treatment, before treating fracture.


    Ii nerve injury

    ii. Nerve Injury

    • Common in fractures of the humerus, injuries around elbow & knee.

    • Look for tell tale signs:

      Closed injuries

      • Nerve seldom severed  wait for spontaneous recovery (90% in 4 months).

      • Recovery x occur/nerve studies shows no recovery explore nerve.

        Open fracture

      • Likely complete nerve lesion.

      • Explore during debridement/secondary procedure  repaired.


    Iii vascular injury

    iii. Vascular Injury

    • Fracture around knee and elbow, humeral and femoral shafts  ↑ ass. w. damage to major artery.

    • Cut, torn, compressed, contused by initial injury/jagged bone fragments.

    • N outward appearance  intima may be detached, vessel blocked by thrombus, spasm.

    • Effects vary : transient diminutive of blood flow, profound inchaemia, tissue death, peripheral gangrene.


    Tbl 1 orthopedic trauma

    Clinical features

    • Paraesthesia /numbness of toes/fingers

    • Cold, pale, slightly cyanosed weak/absent pulse

    • X ray shows high risk fractures

      Management

    • Angiogram

    • Remove bandages/splint

    • X ray – kinking or compressed  reduction

    • Reassess circulation

    • No improvement  explore via operation

      • Torn  Suture/ replace by vein graft

      • Thrombosed  endarterectomyto restore blood flow


    Iv compartment syndrome

    iv. Compartment Syndrome

    • A group of conditions that result from ↑ pressure within a limited anatomic space (limb compartments), acutely compromising the microcirculation and leading to ischaemia of the muscle.

    • Causes : high risk fractures, infection, operation.


    Tbl 1 orthopedic trauma

    Bleeding, oedema or inflammation

    ↑Tissue pressures in a compartment

    Compromise perfusion

    Tissue hypoxia

    Damage to the structures coursing through that compartment (nerves & muscles)

    Prolonged muscle hypoxia

    Necrosis and permanent posttraumatic muscle contracture (Volkmann's ischemia)

    12 hours or less


    Pathophysiology

    Pathophysiology

    VICIOUS CYCLE OF VOLKMANN’S ISCHAEMIA


    Clinical features

    Clinical Features

    • Ischaemia (5 Ps):

      • Pain : Earliest symptom  bursting sensation

      • Paraesthesia

      • Pallor

      • Paralysis

      • Pulselessness

    • Muscles sensitive to touch  ↑ calf/forearm pain when is hyper-extended.


    Tbl 1 orthopedic trauma

    • Pressure of fascial compartment:

      • Introduce catheter into compartment  measure P close to compartment.

      • Diastolic P – compartment P.

      • Differential less than 30 mmHg.


    Treatment

    Treatment

    • Decompression

      • Remove bandage, casts, dressings.

    • Fasciotomy


    V haemarthrosis

    v. Haemarthrosis

    • Joint is swollen, tense.

    • Pt resists any attempt to move it.

       Aspirate blood first.


    Vi infection

    vi. Infection

    • Common in open fractures, unless closed fracture is opened.

    • Chronic osteomyelitis.

    • Slow union, w ↑ chance of re-fracturing

    • Imflamed wound, w seropurulent discharge.

    • Send for C&S.

    • Start antibiotic.


    Vii gas gangrene

    vii. Gas gangrene

    • Produced by clostridial infection esp Clostridum welchii in dirty wounds

    • Destroy cell walls  necrosis  spread of disease

    • Appear within 24 hours on injury

    • Intense pain,swelling,brownish discharge, ↑ HR, characteristic smell, gas formation

    • Toxaemic  coma  death


    Process of fracture healing

    Process of Fracture Healing


    Tbl 1 orthopedic trauma

    TISSUE DISTRUCTION AND HEMATOMA FORMATION

    How Fracture Heal?

    INFLAMMATION AND CELLULAR FORMATION

    CALLUS FORMATION

    REMODELLING


    Tbl 1 orthopedic trauma

    Fracture Healing Process

    • Stage 1: start few days after injury and continue for about a month.

    • Stage 2: starts within a week or two and continues for many months.

    • Stage 3: continues for many month to a few years.


    Late complications of fracture

    Late Complications of Fracture


    Local complication

    Local Complication

    • Deformity

    • Osteoarthritis of adjacent / distant joint

    • Aseptic necrosis

    • Traumatic Chondomalacia

    • Reflex sympathetic dystrophy


    Local complication cont

    Local Complication (cont’)

    • Contractures

    • Myositis ossificans

    • Avascular necrosis

    • Algodystrophy (or Sudeck's atrophy)

    • Osteomyelitis


    Systemic complication

    Systemic Complication

    • Gangrene

    • Tetanus

    • Septicemia

    • Fear of mobilizing

    • Osteoarthritis


    Non union fracture definition classification and management

    Non Union Fracture – Definition, Classification and Management


    What is mobility to the fracture site but painless

    What is mobility to the fracture site but painless?

    A sign of non-union (pseudoarthorsis)


    Non union

    Non- Union

    • The fracture will never unites without intervention

    • Clinical features:

      • Movement can be elicited at the fracture site

      • Pain diminishes


    Tbl 1 orthopedic trauma

    • Causes:

      • Distraction and separation of fragments

      • Interposition of soft tissues between the fragments

      • excessive movements at the fracture site

      • Poor local blood supply

      • Severe damage to soft tissues

      • Infection

      • Abnormal bone


    Tbl 1 orthopedic trauma

    • Classification:

      • Hypertrophic (hypervascular)

      • Oligotrophic

      • Atrophic (avascular)


    Delayed union

    Delayed Union

    • The period in which the fracture is expected to unite and consolidate is prolonged

    • Causes (as non-union)

    • Clinical features:

      • Tenderness persists

      • Mobilization at the fracture site


    Tbl 1 orthopedic trauma

    • X-ray:

      • Fracture line visible

      • Little callus formation

      • Bone ends not sclerosed or atrophic

      • The appearance suggests the fracture has not united but eventually will


    Tbl 1 orthopedic trauma

    • Treatment:

      • Conservatives

        • Eliminate possible causes of delayed union

        • Promote healing i.e. immobilization

      • Operative

        • Internal fixator & bone grafting are indicated when there is delayed > 6 months & no sign of callus formation


    Take home message

    Take Home Message!

    • Read up the Anatomy!

    • Fracture – Types and Patterns

    • Reduce! Hold! Exercise!

    • Acute and Late Complications

    • Process of Fracture healing

    • Non Union Fracture – Classification, Clinical features and Management


  • Login