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Displacement. Described as: Distal in relation to proximal Un-displaced Shift Sideways Shortening Distraction Angulation In all planes Rotation. Fracture Diagnosis. Clinical features Imaging: Radiology (x-Ray). Clinical Features. History of Trauma Symptoms and signs: Pain Swelling

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displacement
Displacement
  • Described as: Distal in relation to proximal
  • Un-displaced
  • Shift
    • Sideways
    • Shortening
    • Distraction
  • Angulation
    • In all planes
  • Rotation
fracture diagnosis
Fracture Diagnosis
  • Clinical features
  • Imaging: Radiology (x-Ray)
clinical features
Clinical Features
  • History of Trauma
  • Symptoms and signs:
    • Pain
    • Swelling
    • Deformity
    • Bony tenderness
    • Abnormal movement
    • Crepitus
    • Loss of function
approach history
Approach - history
  • Details of injury
    • Mechanism, force, bleeding, consciousness, …
  • Details of facture
    • Deformity, pain, loss of function, ..
  • Other medical problems
  • Anti-tetanus status if open injuries
  • Careful:
    • Fractures are not always at the site of impact
    • Some fractures do not need severe force
approach clinical exam
Approach – clinical exam
  • General medical condition
    • should be evaluated to exclude
      • shock
      • brain injury
      • other problems
  • Vital signs
    • should be observed and followed up
approach clinical exam1
Approach – clinical exam
  • Look:
    • Adequate exposure
    • General on patient
    • Local:
      • Swelling, deformity, bruises, color, …
      • Special attention is to be paid to wounds
approach clinical exam2
Approach – clinical exam
  • Feel:
    • Tenderness, distal pulses, temperature and crepitus on movement
    • Sensory and motor deficits
    • Pulse distal to injury
    • Compartment syndrome
  • Move:
    • With care
      • make sure not to cause more pain or injury
    • Crepitus &abnormal movement indicates a fracture
    • Joints distal to the affected area
approach clinical exam3
Approach – clinical exam
  • Examination of the viscera
    • Liver and spleen in rib fractures
    • Urinary bladder and urethra in pelvic fractures
    • Neurological examination in head and spinal injury
investigations imaging
Investigations - Imaging
  • X-rays:
    • Low of 2s
      • Two views: AP and Lateral
      • Two joints: Above and Below
      • Two sides: Right and Left
      • Two occasions
      • Two Doctors !
    • Special views:
      • Obliques, Tunnel view, skyline, functional flexion / extension
    • Arthrography:
      • Shows intra-articular structures
      • Functional in hip
imaging
Imaging
  • Plain x-ray:(law of twos)
    • Two views:AP and Lateral

AP

Lat

AP

Lat

Apley’s System of Orthopedics & Fractures

imaging1
Imaging
  • Plain x-ray:(law of twos)
    • Two views: AP and Lateral
    • Two joints: joint above and joint below

Apley’s System of Orthopedics & Fractures

imaging2
Imaging
  • Plain x-ray:(law of twos)
    • Two views: AP and Lateral
    • Two joints: joint above and joint below
    • Two limbs: for comparison
      • more in children to

compare epiphysis

Apley’s System of Orthopedics & Fractures

imaging3
Imaging
  • Plain x-ray:(law of twos)
    • Two views: AP and Lateral
    • Two joints: joint above and joint below
    • Two limbs: for comparison
      • more in children to

compare epiphysis

    • Two occasions
      • e.g. stress fractures
      • e.g. scaphoid fracture

Apley’s System of Orthopedics & Fractures

imaging4
Imaging
  • Plain x-ray:(law of twos)
    • Two views: AP and Lateral
    • Two joints: joint above and joint below
    • Two limbs: for comparison
      • more in children to

compare epiphysis

    • Two occasions
      • e.g. stress fractures
      • e.g. scaphoid fracture
    • Two injuries
      • e.g. patellar fracture and hip injury
      • e.g. calcaneal fractures & spine injuries

www.jumpintheair.com

imaging5
Imaging
  • Plain x-ray:(law of twos)
    • Two views: AP and Lateral
    • Two joints: joint above and joint below
    • Two limbs: for comparison
      • more in children to

compare epiphysis

    • Two occasions
      • e.g. stress fractures
      • e.g. scaphoid fracture
    • Two injuries
      • e.g. calcaneal fractures & spine injuries
    • .....and two Doctors!

www.123rf.com/

imaging6
Imaging
  • Plain x-ray: (law of twos)
  • Special views:
    • Calcaneal view
    • Shoulder dislocation: axial view
    • Scaphoid views
    • Acetabular fractures: 45o tilt views

http://osuemed.wordpress.com/

imaging7
Imaging
  • CT Scan:
    • In complex and ntra-articular fractures
    • In spine
    • In pelvic and acetabular fractures
    • In calcaneal fractures

www.learningradiology.com

imaging8
Imaging
  • MRI
    • Show associated injuries in spinal fractures
    • Associated soft tissue injuries – e.g. knee
    • Hidden fractures:
      • Subtrochanteric (ST) disruption
      • Stress (fatigue) fractures
      • Scaphoid fracture
    • Suspected avascular

necrosis

www.highperformancesports.blogspot.com

www.bjj.boneandjoint.org.uk

fracture healing
Fracture healing
  • A broken bone heels because …..it is broken !

Alan Apley

natural bone healing
Natural bone healing
  • Movement at the fracture site initiates a healing process—callus formation
  • Vascular and cellular response leads to tissue differentiation and mineralization resulting in restoration of mechanical integrity
natural bone healing1
Natural bone healing

http://classes.midlandstech.edu/

cascade of tissue differentiation
Cascade of tissue differentiation

Following a Fracture:

  • Hematoma
  • Granulation tissue
  • Connectivetissue
  • Fibrocartilage
  • Mineral deposition
  • Bone
fracture healing1

bony bridging

Fracture healing
  • Inflammation
    • Hematoma
    • Mesenchymal cells
  • Soft callus
    • Granualation tissue
  • Hard callus
    • Intramembranous bone formation
    • Enchondral ossification
  • Remodeling
cellular and vascular reaction
Cellular and Vascular Reaction

cells haematoma granulation tissue

tissue differentiation
Tissue Differentiation

connective tissue

granulation tissue

Giemsa

tissue differentiation cascade
Tissue Differentiation Cascade

Masson-Goldner

Cartilage formation

Mineral deposition

Bone

fracture healing2
Fracture Healing
  • Conditions necessary for bone healing:
    • Good blood supply
    • Controlled motion
    • No infection
fracture healing3
Fracture Healing
  • Unfavorable factors
    • Impairment of blood supply
    • Infection
    • Excessive movement
    • Presence of tumor
    • Interposition of soft tissue
    • Any form of Nicotine (smoking)
    • Bad nutrition
average healing time
Average healing time
  • Children:
    • Upper limb: 3-4 weeks
    • Lower limb: 2X upper limb (6-8 weeks)
  • Adults:
    • Upper limb: 2X children (6-8 weeks)
    • Lower limb: 2X upper limb (12-16 weeks)
fracture treatment
Fracture Treatment
  • Aim of fracture treatment
    • aid healing,
    • in normal position,
    • avoiding complications
fracture treatment1
Fracture treatment
  • Treat the patient, not only the fracture
  • Reduce the fracture
  • Immobilize the fracture
    • Prevents displacement
    • Alleviates pain
    • Promotes soft tissue healing
  • Mobilize the patient
  • Avoid complications