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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.

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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.
slide3

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.
slide4

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.
slide5

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.
the leg
The Leg
  • Bones
  • Muscles
    • Compartments
  • Blood Supply
  • Nerve Supply
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

slide12

Anterior compartment

Walls :

  • Interosseous membrane
  • Tibia
  • Fibula

Contents :

  • Extensor muscles of the toes
  • Anterior tibial artery
  • Deep peroneal nerve
  • Most susceptible to compartment syndrome.
slide13

Lateral compartment

Walls :

  • Fibula
  • Intermuscular septums

Contents:

  • Peroneal muscles
  • Superficial peroneal nerve
slide14

Superficial Posterior compartment

Walls:

    • Transverse intermuscular septum

Contents :

  • Gastrocnemius
  • Soleus muscles
slide15

Deep Posterior compartment

Walls :

  • Transverse intermuscular septum
  • Interosseous membrane

Contents:

  • Flexor muscles of the foot
  • Tibial artery
  • Tibial nerve
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.
slide22

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.
slide24

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.

slide27

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.
slide29

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.
slide31

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.
slide40

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

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.
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:

slide48
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
slide55

Debridement

Skin graft

Stabilization

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.
slide62

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.
slide65

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.
slide68

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
slide75

TISSUE DISTRUCTION AND HEMATOMA FORMATION

How Fracture Heal?

INFLAMMATION AND CELLULAR FORMATION

CALLUS FORMATION

REMODELLING

slide76

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.
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
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
slide85

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
slide86

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
slide94

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
slide96

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
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