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. • 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 • 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 • Bones • Muscles • Compartments • Blood Supply • Nerve Supply
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 A break in the structural continuity of bone. - Apley’s System of Orthopedics & Fractures, 8th Edition
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 • 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 • 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 • 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.
**View video http://video.about.com/orthopedics/Fractures-1.htmfor better understanding.
At the Hospital • Examine HEAD TOE • Level of consciousness GCS • Remember:
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 – REDUCEAim adequate apposition and normal alignment of the bone fragments Methods:
Transfixing pin passes to:1. Proximal tibia – hip, thigh and knee injuries2. Distal tibia/calcaneum – tibial fractures Balanced skin traction Braun’s frame