Dec 29, 2015
Extremity trauma
General principles
Dr . Almaghrabi Issam
Damascus Hospital
Definition of fracture Loss of continuity in the substance of bone
Causes
1. Causes of trauma Car accident Work accident Sport accident,…
2. Mechanism of trauma Direct shock
Serious soft tissue lesions
• Indirect shock Flexion Torsion compression
General aspects
A. According to the type of bone: Long bones
• Diaphysis• Epiphysis
* extra-articular
* intra-articular: difficult treatment , ↑↑ complications
Short bones• Scaphoid , Calcaneus, Talus,…
Present diagnostic , therapeutic and prognosis problems
Long bones
Diaphysis
• Epiphysis
extra-articular intra-articular
Short bones
soft tissue lesions
B. According to the age Elderly
Minor trauma ↑↑ morbidity & mortality
e.g. femoral neck fracture Young adult
Violent trauma The risk is local , preserve function
Infant
Violent trauma Minor trauma
Fracture avec décollement épiphysaire de type 1
G
D
Fracture en « motte de beurre » et « bois vert«
Diagnosis of fractures
A. History1. Trauma itself :
Circumstances of the accident Mechanism of the injury: direct, indirect Time of accident
2. Traumatized patient Functional signs : pain, immobility… Age , past history.
B. Clinical exam (comparative):i. Local examination : signs of the fracture
Inspection : deformation, edema, hematoma, ecchymosis Palpation : tenderness, abnormal mobility.
ii. Regional examination Cutaneous : open fractures, contusion…. Vascular: peripheral pulse, color & temperature Neurological: e.g. humeral fracture (radial n.)
iii. General examination: Clinical: associated lesions Para clinical : ECG, blood analysis, chest X-ray
C. X-ray examination: Technique:
The rule of 2:
2 views , 2 joints , 2 limbs , 2 times Sometimes a special X-rays, e.g. scaphoid.
Results : Site Type Displacement : depending on the distal fragment.
Pitfalls
Elderly patient + unable to weight bear
→ femoral neck fracture Snuff-box pain + normal X-ray
→ suspected scaphoid fracture Dashboard lesions → 2 patellae , femoral shaft , silent hip
dislocation Calcaneus fracture → the other calcaneus + vertebral
column. Ankle sprain → 5th base metatarsal fracture. Epilepsy + shoulder pain → think about post. dislocation. Monteggia – Galeazzi (associated dislocations)
Elderly patient + unable to weight bear
D 21
D 0Snuff-box pain + normal X-ray
Dashboard lesions
Fall from height
Ankle sprain
Epilepsy Post. dislocation
Galeazzi Fracture
Monteggia Fracture
25
Treatment
Primary aims : Bony union without deformity Restoration of function
ER treatment : Alignment of the fracture Temporary splintage Open fractures : sterile bandage , AB , tetanus
Treatment Simple fractures:
±Reduction + casting : After care of patient in plaster swollen fingers – blue – pain → bivalve the cast
Complex fractures : admission Traction : skin – skeletal Open reduction & internal fixation
Indications Failed closed reduction Fractures cannot be held by closed methods (femoral neck) Intra-articular fractures Multiple injuries Techniques Plates , screws , K-wires , nails Interlocking nail , elastic flexible nails
external fixation: open fractures
Casting
Ostéosynthèse du tibia par plaque vissée
Infant
Flexible Titanium Nailing of Tibia
Ostéosynthèse du col fémoral
Bi polar
Evolution Favorable : consolidation within the expected time . Complications:
Immediate : General : choc Loco-regional : skin , vascular , nerves
Secondary : General : DVT , bed sores , infections , fat embolism Loco-regional : secondary displacement , opening ,
necrosis , Volkmann . Late :
Delayed union , nonunion , malunion , arthritis , AVN Functional : pain , stiffness , Sudeck . infection
Volkmann
Non union
Malunion
Sudeck atrophy
Records
Date & time , legible hand writing , employ only common use contractions.
Full record on the day of the admission Write results of X-rays (neg., pos.)
Communications
Telephoning description of the fracture : Age of patient Occupation Type of accident
The rule of 6 A’s
Anatomy (proximal tibia )
Articular
Extra vs Intra
Alignment
A.P. view
Angulation
Lat. view
Apex
Distal fragment
Apposition
75% , 25%
Fracture clinic
What , When 3 A’s (assessment , action , advice) When , What
What , When
What : What we are dealing with (diagnosis)
Recording ↓↓ duplication.
When : Establish the time that has passed since the patient’s
injury
Initial Medical record and X-rays are available.
3 A’s
Assessment : Appropriateness (whether this was the best
treatment )
Action :too tight plaster → split More senior opinion → ↑↑ Outcome.
Advice : It is important to Explain to the patient the nature of his injury,
to keep him Informed of his progress
When , What
When: the date & time of the next appointment .
e.g. ↨ of stitches , ↨ of plaster
What : The purpose of the patients next visit
Save valuable time by avoiding the patient having to wait and seen twice.
QuestionsQuestions???? ????