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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.


  • 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.


  • 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.


  • 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


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



Anterior compartment

Walls :

  • Interosseous membrane

  • Tibia

  • Fibula

    Contents :

  • Extensor muscles of the toes

  • Anterior tibial artery

  • Deep peroneal nerve

  • Most susceptible to compartment syndrome.


Lateral compartment

Walls :

  • Fibula

  • Intermuscular septums

    Contents:

  • Peroneal muscles

  • Superficial peroneal nerve


Superficial Posterior compartment

Walls:

  • Transverse intermuscular septum

    Contents :

  • Gastrocnemius

  • Soleus muscles


  • 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.


    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.


    • 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.




    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.


    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.


    • 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.



    I incomplete fracture
    i. Incomplete Fracture


    I complete fracture
    i. Complete Fracture


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



    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.



    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:


    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



    Gustilo s classification
    Gustilo’s Classification



    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.


    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.


    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.


    • 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



    TISSUE DISTRUCTION AND HEMATOMA FORMATION

    How Fracture Heal?

    INFLAMMATION AND CELLULAR FORMATION

    CALLUS FORMATION

    REMODELLING


    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? Management

    A sign of non-union (pseudoarthorsis)


    Non union
    Non- Union Management

    • The fracture will never unites without intervention

    • Clinical features:

      • Movement can be elicited at the fracture site

      • Pain diminishes


    • Causes: Management

      • 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


    • Classification: Management

      • Hypertrophic (hypervascular)

      • Oligotrophic

      • Atrophic (avascular)


    Delayed union
    Delayed Union Management

    • 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


    • X-ray: Management

      • Fracture line visible

      • Little callus formation

      • Bone ends not sclerosed or atrophic

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


    • Treatment: Management

      • 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! Management

    • 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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