1 - Fractures - Principles 1

8/12/2019 1 - Fractures - Principles 1

1/27

1

Clinical features offractures

By Eman A. Salem


2/27

2

History

Usually includes a history of injury;Followed by inability to use the joint

Fracture is not always at the sight

of injury. ptn age and mech. Of injury are

important

Trivial truma

path. Fracture Pain, bruising, and swelling arecommon symptoms.


3/27

3

Fracture VS. Soft tissue injury

Deformity more suggestive of aFX.

Green stick FX. and elderly with impactedFX. of femoral neck may experience littleor no pain, or loss of function.

Enquire about sympt. of associated injury:numbness, loss of movement, skin pallor,cyanosis, blood in urine, abdominal pain,difficulty with breathing and transient

loss of consciousness.


4/27

4

History cont.

Ask about previous or othermusculoskeletal abnormality

Finally take general medical history.


5/27

5


6/27

6

Examination

Unless purely local injury priority mustbe given to deal with the general effectsof truma

In any case X-ray diagnosis is more

reliable1. Examine the most obviously injured part2. Check for arterial damage3. Test for nerve injury4. Look for injury in distant parts


7/27

7


8/27

8

Look for

Swelling

Bruising

Deformity If skin is intact or not (open VS simple)

Posture of distal extremities and colorof the skin signs of nerve or vesseldamage


9/27

9

Feel

Palpate for localized tenderness In high energy injuries, always

examine spin and pelvis

Vascular and peripheral nerveabnormalities should be tested forboth before and after treatment


10/27

10


11/27

11

Move

Crepitus and abnormal movementtested only in unconscious patients

Ask if patient can move the jointdistal to the injury


12/27

12

Imaging X-ray is mandatory

Rule of twos:

1. Two viewsfracture or dislocation may not be seen in a singleX-ray

At least two views must be obtained

2. Two jointsinclude joints above and below FX.They may be dislocated or fractured

3. Two limbsin children X-ray of uninjured limb are needed forcomparison, because immature epiphysis may confuse the diagnosis


13/27

13

4. Two occasionssome fractures are difficult to detect soon afterinjury, another X-ray a week or two latter may show the lesion. exampleUndisplaced frx. of distal end of clavicle

5. Two injuriessevere force causes injury at more than onelevel

CT and MRIdisplay Frx. patterns in difficult sites such as

vertebral column and acetabulum, and calcaneum

Secondary injuries should always be assumed to haveoccurred unless proven other wise


14/27

14


15/27

15

1.Thoracic injury: Frx. rib or sternum ass. with injury tolung or heart.

2. Spinal cord injury: neurological ex. Is essential tocheck for spinal cord or nerve rootinjuryand toobtain a base line for latter comparison

3. Pelvic and abdominal injury: ass.withvisceral

injuryinquire about urinary function and look for blood inurethral meatus

4. Pectoral girdle injury: may damage brachialplexusor vessels at base of neck. Neurological and

vascular examination are essential


16/27

16

Testing for fracture union

Its impossible to tell when joiningoccurs

Imp. to know:1. Signs of healing

2. When bone can withstand normal

loading


17/27

17

Signs of healing

1. Absences of pain during dailyactivities

2. Absences of tenderness at Frx. site3. Absences of pain on stressing the

Frx.4. Absences of mobility at Frx. Site5. X-ray signs of callus formation,

bone bridging, and finallytrabeculation


18/27

18

Fractures in children1. Difficult to diagnose: Bone ends are largely cartilaginous and

dont show up in X-Ray. It helps to X-Ray both limbs and compare theappearance on both sides.

2. Children bones are less brittle and more liableto plastic deformation. Higher incidence of incomplete fx.Buckling of the cortex and the green stick frx. are rare in adults.

3. Periosteum is thicker than adult bones thatswhy frx. displacement is more controlled. Cellularactivity is increased (frx. heals faster).

4. Non-union is very unusual5. More capacity to reshape frx. Deformitymore

modeling and remodeling.

6. Injury to the physisdamage to growth platecan have serious consequences.


19/27

19


20/27

20

Injuries of the Physis 10% of frx. involve injury to thephysis (growth plate)

If a frx. transverses the cellular(reproductive) layer of the platepremature ossification of injured

part and cessation of growth or bonedeformity.


21/27

21

Classification of physeal

injuriesSalter and Harris: 5 typesType 1:transverse frx. Through the hypertrophicor calcified zone of the plate. Even if frx. Is

severely displaced, growing physis is not injured andthe growth disturbance is uncommon.

Type 2: towards the edge the fracture deviatesaway from the physis and splits of a fractional piece

of metaphyseal bone; growth not affected.


22/27

22

Type 3: frx. partly along the physis and thenveering off through the epiphysis into the joint

space. It damages the reproductive zone andresults in growth disturbance. Type 4: frx. splits the epiphysis but continues

through the physis into metaphysis. Partly liableto displacement and consequent misfit between

separated parts of the physis and results inasymmetrical growth.

Type 5: a longitudinal compression injury of thephysis. No visible fx., growth plate is crushedcausing growth arrest.


23/27

23


24/27

24

Physeal frx.falls and tractioninjury. Mostly in RTA and duringsports or playground activities.

Boys > Girls Any injury in child followed by pain

and tenderness near the joint should

arouse suspicion. X-ray is essential.


25/27

25

X-ray: physeal frx. are difficult todiagnose in younger children.

Compare X-ray with the normal side. A 2ndX-ray after 4-5 days is

essential.


26/27

26

Factors that increase

suspicion of physeal injury1. Widening of physeal gap.

2. Incongruity of the joint.

3. Tilting of the epiphyseal axis.


27/27

1 - Fractures - Principles 1

Documents