FRACTURES Anandkumar Balakrishna Wong Poh Sean Mohd Hanafi Ramlee CONTENT DEFINITION PRINCIPLE MANAGEMENT COMPLICATIONS DEFINITION A fracture is a break in the structural continuity of bone. CAUSES Sudden trauma direct(fracture of the ulna caused by blow on the arm) indirect(spiral fractures of the tibia and fibula due to torsion of the leg, vertebral compression fractures, avulsion fractures) Stress or fatigue-repetitive stress(athletes, dancers, army recruits) Pathological(osteoporosis, Paget’s disease, bone tumour) TYPES OF FRACTURES CLOSED/ SIMPLE •no opening in the skin. OPEN/ COMPOUND •bone fragments have broken through the skin. COMPLETE INCOMPLETE • bone is completely broken into 2 or more fragments. • -eg: • transverse fracture • oblique fracture • spiral fracture • impacted fracture • comminuted fracture • segmental fracture • bone is incompletely divided and the periosteum remains in continuity. • -eg: • greenstick fracture • torus fracture • stress fracture • compression fracture. COMPLETE FRACTURES OBLIQUE FRACTURE SEGMENTAL FRACTURE TRANSVERSE FRACTURE SPIRAL FRACTURE COMMINUTED FRACTURE IMPACTED FRACTURE INCOMPLETE FRACTURE GREENSTICK TORUS FRACTURES DISPLACEMENT After a complete fracture the fragments usually displaced: partly by the force of injury partly by gravity partly by the pull of muscles attached to them. 4 types: Translation/Shift Alignment/Angulation Rotation/Twist Altered length ANGULATION /TILT SHIFT SIDEWAYS OVERLAP IMPACTION TWIST/ ROTATION HOW FRACTURES HEAL? Healing by callus Healing without callus Healing by callus Callus is the response to movement at the fracture site to stabilize the fragments as rapidly as possible. Steps: Tissue destruction and haematoma formation. Inflammation and cellular proliferation. Callus formation: dead bone is mopped up & woven bone(immature) appears in fracture callus. Consolidation: woven bone(immature) is replaced by lamellar bone(mature). Remodelling:Newly formed bone is remodelled to resemble the normal structure. Healing without callus For fracture that is absolutely immobile: impacted fracture in cancellous bone. fracture rigidly immobilized by internal fixation New bone formation occurs directly between fragments. Gaps between the fracture surfaces are invaded by new capillaries & bone forming cells growing in from edges. For very narrow crevices(<200um), osteogenesis produces lamellar bone(mature). For wider gaps, osteogenesis begins with woven bone (immature) first which is then remodelled to lamellar bone (mature bone). RATE OF REPAIR DEPENDS UPON: Type of bone Type of fracture State of blood flow cancell ous bone heals faster than cortical bone. spiral fracture heals faster than transver se fracture. poor circulati on will slow the healing process. Patient’s general constitution Patient’s age healthy bone heals faster. healing is faster in children than adults. CAUSES OF DELAYED UNION OR NON-UNION OF THE FRACTURES Distraction & separation of the fragments Interposition of soft tissues between the fragments. Excessive movement at the fracture site Poor local blood supply Severe damage to soft tissues which makes them nearly/nonviable. Infection Abnormal bone. FRACTURESPRINCIPLE OF TREATMENT Management of Closed Fracture First aid management Airway, Breathing and Circulation Splint the fracture Look for other associated injuries Check distal circulation – is distal circulation satisfactory? Check neurology – are the nerve intact? AMPLE history- Allergies, Medications, Past medical history, Last meal, Events Radiographs – 2 views, 2sides, 2 joints, 2 times. General Resuscitation Manipulation (improve position of fragments) Splintage (hold fragments together until unite) Exercise & weight-bearing Reduce Hold Exercise Principle Of Treatment Hold Safety Speed Move The Fracture Quartet Closed Fracture Outline Closed Reduction Reduce Mechanical Traction Open Reduction Sustained Traction Cast Splintage Hold Functional Bracing Exercise Internal Fixation External Fixation Reduce Aim for adequate apposition and normal alignment of the bone fragments The greater contact surface area between fragments, the more likely is healing to occur However, there are some situations in which reduction is unnecessary: When there is little or no displacement When displacement does not matter (e.g. in some fractures of the clavicle) When reduction is unlikely to succeed (e.g. with compression fracture of the vertebrae) Reduction Operative Non-operative Closed reduction Open reduction Mechanical Traction Closed Reduction Suitable for Minimally displaced fractures Most fractures in children Fractures that are likely to be stable after reduction Most effective when the periosteum and muscles on one side of fracture remain intact Under anaesthesia and muscle relaxation, a threefold manoeuvre applied: Distal part of the limb is pulled in line of the bone Disengaged, repositioned Alignment is adjusted Mechanical Traction Some fractures (example fracture of femoral shaft) are difficult to reduce by manipulation because of powerful muscle pull However, they can be reduced by sustained muscle mechanical traction; also serves to hold the fracture until it starts to unite Open Reduction Operative reduction under direct vision Indications: When closed reduction fails When there is a large articular fragment that needs accurate positioning For avulsion fractures in which the fragments are held apart by muscle pull When an operation is needed for associated injuries When a fracture needs an internal fixation Hold Non Operative • Sustained traction • Cast Splintage • Functional Bracing Operative • Internal Fixation • External Fixation HOLD To prevent displacement To alleviate pain by some restriction of movement To promote soft-tissue healing To allow free movement of the unaffected parts Sustained Traction • • Traction is applied to limb distal to the fracture To exert continuous pull along the long axis of the bone Hold Speed Safety Move Advantage •Can move joint •Can exercise musle Indication •Useful for spiral fractures of long bone shafts: •Shaft of femur •Tibia •Lower humerus Disadvantage and complications Patient kept on bed for long time Pressure ulcer General weakness Pulmonary infection Contracture Pin tract infection Thromboembolic event Methods Traction by gravity Balanced traction Fixed traction Traction By Gravity Example: Fracture of humerus -Weight of arm to supply traction -Forearm is supported in a wrist sling Balanced Traction Traction is applied to the limb either by way of adhesive strapping, kept in place by bandages skin traction • Sustain a pull no more than 4-5 kg Contraindications: • Abrasion, dermatitis, wound • Vascular insufficiencies • When greater traction force in needed Thomas’s Splint Traction applied via stiff wire or pin inserted through the bone distal to the fracture skeletal traction • Can apply several times as much force Complications: • Pin tract infection • Damage to epiphyseal growth plate • Vertical fracture of the bone • Injury to the vessels or nerves Fixed Traction Principle = balanced traction Useful for when patient has to be transported Thomas’s splint Cast Splintage Methods: Plaster of Paris Fibreglass Especially for distal limb # and for most children # Disadvantage: joint encased in plaster cannot move and liable to stiffen Can be minimized: Delayed splintage (traction initially) Replace cast by functional brace after few weeks Complications Tight cast put on too tightly/limb swells Hold Speed Safety Move Pressure sores even a well-fitting cast may press upon the skin over a bony prominence (the patella, the heel) Skin abrasion or laceration during removal of the plaster Functional Bracing Brace supportive device that allows continued function of the part Principle functional long bone is supported externally by POP or by a mouldable plastic material but the function of joints are preserved Indication fractures of shaft of femur or tibia Functional bracing is not rigid applied when fracture is beginning to unite, after about 3-6 weeks of traction or restrictive splintage Advantages: • • • • Fractures held reasonably well Joints can be moved Patient can leave hospital Method is safe Hold Safety Speed Move INTERNAL FIXATION Principle Bony fragment may be fixed with: • screws, • transfixing pins or nails, • a metal plate held by screws, • a long intramedullary nails, • circumferential band, • or a combination with these method Indication 1. Fracture that cannot be reduced except by operation 3.Fracture that unite poorly and slowly • Principally fracture of the femoral neck 5.Multiple fracture • Where early fixation reduced the risk of general complication 2. Fracture that are inherently unstable and prone to displacement after reduction 4.Pathological fracture • Bone disease may prevent healing 6.Fracture in patient who present severe nursing difficulty Type of internal fixation screw • Interfragmentary screw (lag screw) are used for fixing small fragment onto the main bone wires • Kirschner wire (often inserted percutaneously without exposing the fracture • Used in situation where fracture healing is predictably quick Plates and screw • Useful for treating metaphyseal fracture of long bones and diaphyseal fracture of radius and ulna Intramedullary nail • Suitable for long bones • Nail is inserted onto medullary canal to splint the fracture • Rotational of fracture are resisted by introducing locking screw which tranfix the bone cortices and the nail proximal and distal to the fracture. advantages Precise reduction •ORIF-open reduction and internal fixation Immediate stability •Hold the fracture securely Early movement •‘fracture disease ‘ like oedema,s tifness,etc may abolish Infection Refracture Complications Implant failure Non-union Infection Iatrogenic infection chronic osteomylitis Risk of infection depends on: 1)The patient devitalised tissue, dirty wound, unfit patient 2)The surgeon thorough training, a high degree of surgical dexterity and adequate assistant are all essential 3) The facilities aseptic routine The infection should be rapidly controlled by intravenous antibiotic If infection cannot be controlled, the implant should be replaced with some form of externalfixation Non union Cause: 1)excessive stripping of soft tissue 2)unnecessary damage to blood supply in the course of operativefixation 3)rigid fixation with a gap between the fragment Implant failure Metal is subjected to fatigue • • • Metal is subjected to fatigue So, undue stress should therefore be avoided until the fragment has united. Pain at the site of fracture site is a danger signal. Refracture • • • It is important not to remove the metal implant too soon A year is minimum and 18 to 24 month is safer For several weeks after the implant removal the bone is weak so full weightbearing should be avoided EXTERNAL FIXATION Principle The bone is transfixed above and below the fracture with screw or pins or tension wire and these are then clamped to a frame or connected to each other by rigid bars outside the skin Indication Fracture associated with soft tissue injury Severely comminuted and unstable fracture • Where the wound can be left open for inspection, dressing and definitive coverage • Which can be held out to length until healing commence Fracture of the pelvis • Which often cannot be controlled quickly by any other method Fracture associated with nerve and vessel damage Infected fracture United fracture • Where internal fixation might not be suitable • Where dead or sclerotic fragment can be excised and the remaining ends brought together in the external fixator (a)The patient was fixed with a plate and screw but did not unite (b) external fixation was applied Advantages technically quick and easy to perform ease of removing hardware; no soft tissue stripping; risk of infection at the site of the fracture is minimal Complication Damage to soft tissue structure Over distraction Pin track infection Damage to soft tissue structure • Transfixing pins and wires may injure the nerve and vessel or may tether ligament and inhibit joint movement • So, the surgeon must be thoroughly familiar with the ‘safe corridor’ for inserting the pins Over distraction •If there is no contact between the fragment, union may be delayed or prevented Pin track infection •There is a risk of infection where the pins are inserted from the skin into the bone. •So, meticulous pin-site care is essential •Antibiotic should be administered immediately if infection occur Exercise Prevention of edema active exercise and elevation Active exercise also stimulates the circulation. Prevents soft-tissue adhesion and promotes fracture healing. Preserve the joint movement Restore muscle power Functional activity Management of Open Fractures A break in skin and underlying soft tissues leading directly to communicating with the fracture Open Fracture First Aid & Management of the Whole Patient Prompt wound debridement Antibiotic prophylaxis Stabilization of the fracture Definitive wound cover First Aid & Management of the Whole Patient Airway Breathing Circulation 80 1. Emergency Management of Open Fracture A,B,C Splint the limb Sterile cover - prevent contamination Look for other associate injury Check distal circulation – is distal circulation satisfactory? Check neurology – are the nerve intact? AMPLE history- Allergies, Medications, Past medical history, Last meal, Events Radiographs – 2 view, 2sides, 2 joints, 2 times. Relieve pain Tetanus prophylaxis Antibiotics Washout / Irrigation Wound debridement fracture stabilisation Open Fractures Classification Preoperative Assessment HISTORY Age General health & comorbidities PHYSICAL EXAMINATION ATLS Other injuries Vascular status of limb • Limb color, pulse, capillary refill Neurological status of limb Alcohol & drugs Ambulatory status Cause of injury • High or low energy • Potential for infection • Previous injuries • Power, sensation Preoperative Assessment EXAMINATION OF OPEN WOUND Location & extent of the wound Length of wound Number of skin wounds Degree of skin contamination RADIOLOGICAL EXAMINATION X-ray: AP, lateral CT & MRI: open pelvic, intraarticular, carpal, tarsal fractures Treatment- Outline Irrigation Debridement: Skin, Fat, Muscle, Bone Wound closure Analgesic + Antibiotic + Antitetanus (AAA): IV, IM Fracture stabilization 1) Analgesic + Antibiotic + Antitetanus Prophylaxis Analgesic Pethidine/morphine 60-70% of open wound are associated with positive cultures, mostly normal flora Broad spectrum 3rd generation cephalosporin, aminoglycoside Gentamicin or metronidazole for gram negative organism. Antitetanus Toxoid for immunised Human antiserum for non-immunised Antibiotic • • • • Gustilo Grade I- first generation of cephalosporin for 72 hours Gustilo Grade II- first generation cephalosporin for 72 hours + Gram negative coverage (gentamicin) for at least 72 hours Gustilo Grade III- first generation cephalosporin +G –ve coverage for at least 72 hours For soil contamination- penicillin is added for clostridial coverage 2) Irrigation Fluids such as normal isotonic saline or antibiotic solutions + hydrogen peroxide A method of wound cleansing by removing debris mechanically with pressurised fluid. Advantages: •Flushes away the foreign matter and contaminated blood clot •Helps in assessment of viability of tissues •Reduces bacterial population 3) Debridement All dead and contaminated tissues must be removed Performed in a systematic manner • • • • Skin & fascia Muscles Tendon Bone 89 Surgical Debridement Type II and type III require surgical debridement. Important aspect of wound management. Reduce bacteria, remove foreign bodies, remove devitalized tissue. Removal of dead tissue reduces bacterial burden and accelerate healing. 4) Wound Closure Primary closure • For wounds less than 8 hours old after debridement Delayed primary closure (<5days) • Wound left open after debridement for 2-3 days • If clean, close the wound Another debridement Secondary closure Skin grafting • Type III • For infected wound • Partial thickness • Full thickness Wound Closure Uncontaminated I & II can be sutured – provided without tension All other wounds left open, packed with moist sterile gauze, to be inspected 24-48 hours – primary delayed closure If wound cannot be closed without tension – skin grafting 5) Fracture Stabilization Immobilisation in a plaster Skeletal traction • A window is made in the plaster over the wound for dressing • Eg. open fracture of tibia External fixator • • • • Internal fixator • Rarely used Can be easily applied Readily reduced and adjusted Wound can be assessed for dressing Excellent stability Stabilization of the fracture To reduce infection and assist recovery of soft tissue Depends on: degree of contamination length of time from injury to operation amount of soft tissue damage If <8 hours: up to IIIA treated as closed fractures: Splintage Intramedullary nailing Plating External Others: fixation External fixation Aftercare The limb is elevated & it's circulation carefully monitored Antibiotic cover If the wound has been left open, it is inspected after 2-3 days & covered appropriately Physiotherapy and rehabilitation COMPLICATION OF FRACTURE Early Late Shock Diffuse Coagulopathy Tetanus Respiratory Dysfunction DVT & Pulmonary Emb. Fat Emboli Syndrome Crush Syndrome Chest Infection Urinary Tract Infection Gas Gangrene Bone Infection Non-union / Mal-union / Delayed union Avascular Necrosis Length discrepancy Disuse Osteoporosis BONE Joint Haemarthrosis Ligament injury JOINT General GENERAL Soft Tissue Plaster Sore Tendon Rupture Neurovascular Injury Compartment Syndrome Visceral injury Instability / Mal-alignment Osteoarthritis Stiffness Overuse injuries Nerve compression Volkmann’s contracture Bedsores Myositis Ossificans Tendinitis & Tendon rupture SOFT TISSUE General Complications 1. 2. 3. 4. 5. 6. 7. 8. Shock Diffuse coagulopathy Respiratory dysfunction Crush syndrome Venous thrombosis & Pulmonary embolism Fat embolism Gas Gangrene Tetanus General 1: Shock Altered physiologic status with generalized inadequate tissue perfusion relative to metabolic requirements. irreversible damage to vital organs Cardiogenic Neurogenic Hypovolemic • direct injury to heart effect the pump functions • injury to brain stem (vasomotor center) spinal cord loss of sympathetic tone increase venous capacitance low venous return àlow cardiac output (but bradycardia) • reduction of blood volume 1500-3000ml 500-1000ml 1500-3000ml 100-300ml 1000-2000ml 1000-2000ml VOLUME DISTRIBUTION General 1: Shock Why we need to treat shock? • Blood redistribution • Renal shutdown • Intestinal ischemia • Tissue hypoxia • Metabolic acidosis • Reduced hepatic blood flow • Acute Respiratory Distress Sydrome • Altered consciousness How to manage shock? • Identify: Thirst, rapid shallow breathing, the lips and skin are pale and the extremities feel cold, impaired renal function test and decreased urinary output. • ABC • IV lines: fluids and blood • Oxygenation/Ventilation • Urinary Catheter • Central Venous Pressure • Ionotropic drugs General 2: DIFFUSE COAGULOPATHY Consumptive Coagulopathy •activation by tissue thromboplastin •endothelial injury activating platelets •massive blood transfusion Management •Stop the bleeding •Fresh Frozen Plasma (FFP) •Cryoprecipitate •Platelet transfusion •Heparin General 3: RESPIRATORY DYSFUNCTION Pathophysiology Management •Alveolar edema •endothelial injury •capillary permeability •Poor lung compliance •inactivated surfactant •Arterial hypoxemia •Oxygenation •Ventilation •positive end expiratory pressure (PEEP) General 4: Crush Syndrome [traumatic rhabdomyolitis] Serious medical condition characterized by major shock & renal failure following a crushing injury to skeletal muscles or tourniquet left too long Bywaters’ Syndrome When compression released Myohaemati n release from cells Nephrotoxic effects Block tubules Oliguria, uremia, metabolic acidosis General 4: Crush Syndrome Clinically • Shock • Pulseless limb redness swelling • Loss of muscle sensation and power • Decrease renal secretion • Uremia, acidosis • Prognosis • If renal secretion return within 1 week the patient survive • But most of them die within 14 days Management • PREVENTION • Strict tourniquet timing • Amputation • limb crushed severely • tourniquet left on > 6 hrs • above site of compression & before compression released • Monitor intake & output • Dialysis • Correct electrolytes & acidosis • Antibiotics General 5: Deep vein thrombosis and pulmonary embolism. Virchow’s triad factor Clot formation in large vein thrombus breaks off Emboli Site: leg, thigh and pelvic vein. Risk factors: Knee and hip replacement Elderly Cardiovascul ar disease Immobility Trauma Malignancy Hypercoagul able status General 5: Management Deep vein thrombosis and pulmonary embolism. PREVENTION Correct hypovolemia Calf muscle exercise Proper positioning Well fitting bandages & cast Limb elevation Graduated compression stockings Calf muscle stimulation Anticoagulation Ambulate patient Established thrombosis/embolism Limb elevation Heparinization Thrombolysis Oxygenation or ventilation General 6: Fat Embolism Fat globules from marrow pushed into circulation by the force of trauma that causing embolic phenomena Fractures that most often cause FES • Long bones • Ribs • Tibia • Pelvis Closed/ope n Fracture Fat in bone marrow escape Formation of fat globules in vessels Triad of symptoms Stick in target organ Fat embolus General 6: Fat Embolism Triad of Symptoms • Brain: mental confusion • Lung: breathlessness, ARDS • Skin: Petechia Management • Prevent hypoxemia • oxygenation or ventilation • Rule out head injury • CT Scan of brain • Monitor fluid & electrolyte balance • CVP, urinary catheter General 6: Fat Embolism SKIN: Fat droplets obstruct alveolar capillaries thromboplastin release consumption of coagulation fx & platelets DIVC/Skin necrosis Petechia LUNG: Fat droplets obstruct alveolar capillaries thromboplastin release alter membrane permeability / lung surfactant oedema respiratiory failure [V/Q Mismatch] BRAIN: Fat droplets obstruct capillaries confusion coma/fits death General 7: Gas Gangrene Rapid and extensive necrosis of the muscle accompanied by gas formation and systemic toxicity due to clostridium perfringens infection Clinical Features Management • sudden onset of pain localized to the infected area. • swelling , edema • +/- pyrexia • profuse serous discharge with sweetish and mousy odor . • Gas production • early diagnosis . • surgical intervention and debridement are the mainstay of treatment. • IV antibiotics • fluid replacement. • hyperbaric Oxygen General 7: Gas Gangrene Prevention: ALL DEAD TISSUE [4C] SHOULD BE COMPLETELY EXCISED, General 8: Tetanus A condition after clostridium tetani infection that passes to anterior horn cells where it fixed and cant be neutralized later produces hyper-excitability and reflex muscle spasm Clinical Features • Tonic and clonic contractions of esp. jaw, face, around the wound itself ,neck ,trunk, finally spasm of the diaphragm and intercostal muscles leads to asphyxia and death. Management • Prophylaxis • Treatment • Antitoxin & antibiotic • Muscle relaxant • Tracheal intubation • Respiration control Early Complications 1. 2. 3. 4. 5. 6. Visceral Injury Vascular Injury Compartment Syndromes Nerve injury Haemarthrosis Infection Early 1: Visceral injury Fractures around the trunk are often complicated by visceral injury. E.g. Rib fractures pneumothorax / spleen trauma / liver injuries. E.g. Pelvic injuries bladder or urethral rupture / severe hematoma in the retroperitoneum . Rx: Surgery of visceral injuries Early 2: Vascular injury Commonly associated with highenergy open fractures. They are rare but well-recognized. Mechanism of injuries: The artery may be cut or torn. Compressed by the fragment of bone. normal appearance, with intimal detachment that lead to thrombus formation. segment of artery may be in spasm. It may cause Transient diminution of blood flow Profound ischaemia Tissue death and gangrene 5P’s of ischemia Early 2: Vascular injury Pain Pallor Pulseless Paralysis Paraesthesia X-ray: suggest high-risk fracture. Angiogram should be performed to confirm diagnosis. Early 2: Vascular injury muscle ischaemic is irrevesible after 6 hours. Remove all bandages and splint & assess circulation Skeletal stabilization – temporary external fixation. Definitive vascular repair. Vessel sutured endarterectomy Injury Vessel 1st rib fracture subclavia n Shoulder dislocation Axillary Humeral supracondylar fracture Brachial Elbow dislocation Brachial Pelvic fracture Presacral and internal iliac Femoral supracondylar fracture Femoral Knee dislocation Popliteal Proximal tibial fracture Popliteal or its branches Early 3: Compartment Syndrome A condition in which increase in pressure within a closed fascial compartment leads to decreased tissue perfusion. Untreated, progresses to tissue ischaemia and eventual necrosis Leg • 4 compartments: anterior, lateral, superficial and deep posterior • NOT interconnected Forearm • 3 compartments: dorsal, superficial and deep volar • interconnected, hence fasciotomy of 1 compartment may decompress the other 2 Early 3: Compartment Syndrome Most common sites (in ↓ freq): leg (after tibial fracture) → forearm → thigh → upper arm. Other sites: hand, foot, abdomen, gluteal and cervical regions. High # risk injuries: of elbow, forearm bones, and proximal 3rd of tibia (30-70% after tibial #) multiple fracture of the foot or hand crush injuries circumferential burns Early 3: Compartment Syndrome [aetiology] ↑ Compartmental volume (↑ fluid content) • Trauma – fractures /osteotomies, crush injury • Vascular – haemorrhage, post-ischaemic swelling • Soft tissue injury – burns, prolonged limb compression • Iatrogenic – intraosseous fluid resuscitation in children, intraarterial drug injection • Extreme muscular exertion ↓ Compartment volume (constriction of the compartment) • Constrictive dressings/plaster casts • Thermal injuries with eschar formation • Pneumatic antishock garments (MAST) • Surgical closure of fascial defects Vicious cycle ↑ fluid content Early 3: Compartment Syndrome Constriction of compartment ↑ INTRACOMPARTMENTAL PRESSURE Obstruct venous return Capillary basement membranes become leaky → oedema Vascular congestion Muscle and nerve ischaemia Further ↑ intracompartmental pressure ↓ capillary perfusion Compromise arterial circulation → PROGRESSIVE NECROSIS OF MUSCLES AND NERVES !! Sequence started with: severe pain/bursting sensation (early) paraesthesia/hypoaesthesia motor weakness loss of peripheral pulses and capillary refill (late signs, poor prognosis) A vicious circle that ends after 12 hours or less Necrosis of the nerve and muscle within the compartment Nerve -capable to regenerate Muscle -infarcted Never recover Replaced by inelastic fibrous tissue ( Volkmann’s ischaemic contracture) Investigations of compartment sydromes Intra-compartment Pressure Measurement (ICP) Use of slit catheter; quick and easy Indications: Unconscious patient Those who are difficult to assess Concomitant neurovascular injury Equivocal symptoms Especially long bone # in lower limb Perform as soon as dx considered > 40mmHg – urgent Rx! (normal 0 – 10 mmHg) Investigations of compartment syndromes Other Ix – limited value; +ve only when CS is advanced Plasma creatinine and CPK Urinanalysis – myoglobinuria Nerve conduction studies Ix to establish underlying cause or exclude differentials X-ray of affected extremity Doppler US/arteriograms – determine presence of pulses; exclude vascular injuries and DVT PT/APTT – exclude bleeding disorder Management Prompt DECOMPRESSION of affected compartment Remove all bandages, casts and dressings Examination of whole limb Limb should be maintained at heart level Elevation may ↓ arterio-venous pressure gradient on which perfusion depends Ensure patient is normotensive. Hypotension tissue injury. ↓ tissue perfusion, aggravate the Management Measure If intra-compartment pressure > 40mmHg Immediate If open fasciotomy < 40mmHg Close observation and re-examine over next hour If condition improve, repeated clinical evaluation until danger has passed Don’t wait for the obvious sings of ischemia to appear. If you suspect An impending compartment syndrome, start treatment straightaway Fasciotomy Opening all 4 compartments Divide skin and deep fascia for the whole length of compartment Wound left open Inspect 5 days later If muscle necrosis, do debridement If healthy tissue, for delayed closure or skin grafting Complications Volkmann’s ischaemic contracture Motor/sensory deficits Kidney failure from rhabdomyolysis (if very severe) Infection – fasciotomy converts closed # to open # Loss of limb Delay in bone union Prognosis excellent to poor, depending on how quickly CS is treated and whether complications develop Early 4: Nerve Injury It’s more common than arterial injuries. The most commonly injured nerve is the radial nerve [in its groove or in the lower third of the upper arm especially in oblique fracture of the humerus] Common with humerus, elbow and knee fractures Most nerve injuries are due to tension neuropraxia. Injury nerve 1. Shoulder dislocation Axillary 2. Humeral shaft fracture Radial 3. Lower end of radius Median 4. Humeral supracondylar (esp. children) Radial or median(ant.inteross eous) 5. Medial condyle Ulnar 6. Elbow dislocation Ulnar 7. Hip dislocation Sciatic 8. Knee dislocation Peroneal 9. Fracture of fibular neck Peroneal Early 4: Nerve Injury Damaged by laceration, traction, pressure or prolonged ischaemia Neurapraxia • axon remains intact but conduction ceases due to segmental demyelination. Spontaneous recovery in a few days or weeks Axonotmesis • axonal separation with degeneration of distal portions. Sheath remains intact, thus recovery likely but delayed Neurotmesis • nerve completely divided. Spontaneous recovery unlikely. Early 4: Nerve Injury Clinical features Numbness and weakness Skin smooth and shiny but feels dry Muscle wasting and weakness Sensation blunted Tinel’s sign +ve Investigations Electromyography Nerve conduction study May help to establish level and severity of lesion Early 4: Nerve Injury Open injuries Closed injuries • Exploration • Cleanly divided – repair immediately • Torn/crushed – left alone or ends lightly tacked together, re-explore 2 – 3 weeks later for scar tissue removal and suturing • Usually nerve sheath intact • Rate of axonal regeneration = 1mm/day • If no sign of recovery – re-exploration with excision of scar tissue and suturing of clean-cut ends, nerve grafting if gap too large • Splinting 3-6 weeks then physiotherapy Early 5: Haemarthrosis Bleeding into a joint spaces. Occurs if a joint is involved in the fracture. Presentation: swollen tense joint; the patient resists any attempt to moving it treatment: blood aspiration before dealing with the fracture; to prevent the development of synovial adhesions. Early 6: INFECTION Closed fractures – hardly ever Open fractures – may become infected Post traumatic wound – may lead to chronic osteomyelitis Clinical features • wound is inflammed • draining seropurulent fluid Treatment • antibiotic • excise the devitalised tissue • tissues opened & drained the pus Late Complications 1. 2. 3. 4. 5. 6. Delayed Union Non-union Mal-union Avascular Necrosis Osteoarthritis Joint Stiffness Late 1: DELAYED UNION Union of the upper limbs - 4-6 weeks Union of the lower limbs - 8-12 weeks(rough guide) Any prolong time taken is considered delayed Late 1: DELAYED UNION Factors are either biological or biomechanical Biological : Poor blood supply Tear of periosteum, interruption of intramedullary circulation Necrosis of surface# and healing process will take longer Severe soft tissue damage Most important factor Longer time for bone healing cell supply due less inflammatory Infection: bone lysis, tissue necrosis and pus Periosteal stripping Less blood circulation to bone Late 1: DELAYED UNION Mechanical Over-rigid fixation-fixation devise Imperfect splintage Excessive traction creates a gap#(delay ossification in the callus) Late1: DELAYED UNION Clinical features: Tenderness persist Acute pain if bone is subjected to stress* ( * ask pt to walk, move affected limb) X RAYS -visible line# and very little callus formation/periosteal reaction - bone ends are not sclerosed/ atrophic (it will eventually unite) Late 1: DELAYED UNION Tx: conservative and operative Eliminate possible causes of delay Promote healing Immobilization should be sufficient to prevent movement at # site(cast / internal fixation) Not to neglect # loading so, encourage muscle exercise and weight bearing in the cast/brace Operation > 6 mths & no signs of callus formation Internal fixation and bone graffting (operation-least possible damage to the soft tissue) Late 2 : NON-UNION In a minority of cases, delayed union--non-union Factors contributing to non-union: inadequate treatment of delayed union too large gap interposition of soft tissues between the fragments The growth has stopped and pain diminishedreplaced by fibrous tissue - pseudoarthrosis Treatment : conservative / operative atrophic non-union – fixation and grafting hypertrophic non-union – rigid fixation Late 2: NON UNION bone ends are rounded off or exuberant Hypertrophic non union Bone ends are enlarged, osteogenesis is still active but not capable of bridging the gap ‘elephant feet’ on X ray Atrophic non union Cessation of osteogenesis No suggestion of new bone formation A B Non-union X- ray A – Atrophic non- union B – Hypertrophic nonunion Late 2: Non union Tx: Mostly symptomless Conservative Removablesplint For hypertrophic non-union, functional bracing-induce union Pulsed electromagnetic fields and low frequency pulsed u/s can also be used to stimulate union. Operative Hypertrophic--Rigid fixation (internal or external) Atrophic--Excision of fibrous tissue ,sclerotic tissue at bone end, bone grafts packed around the fracture Late 3: MALUNION fragments that are joined in an unsatisfactory position Factors: failure to reduce the fracture failure to hold the reduction while healing proceed gradual collapse of comminuted / osteoporotic bone MALUNION Late 3: Mal-union X-ray are essential to check the position of the fracture while uniting. important- the first 3 weeks so it can be easily corrected Clinical features: Deformity usually obvious , but sometimes the true extent of malunion is apparent only on x-ray Rotational deformity can be missed in the femur, tibia, humerus or forearm unless is compared with it’s opposite fellow Treatment Decision about the need for re-manipulation and correction-difficult In adults Fracture-reduced as near to the anatomical position as possible apposition for healing alignment and rotation is important for function Angulation(>10-15) in long bone or apparent rotational deformity may need correction by re-manipulation or by osteotomy and internal fixation In children angular deformity near the bone ends often remodel with time Rotational deformity will not In lower limb shortening Shortening less than 2 cm: compensated by shoe raise Shortening more than 2 cm: limb lengthening should be consider. Long term effect of mal-alignment (>15) results in asymmetrical loading of joint and results in late development of 2 osteoarthritis. Late 4: AVASCULAR NECROSIS Certain region-known for their propensity to develop ischaemia and bone necrosis Head of femur Proximal part of scaphoid Lunate Body of talus (Actually this is an early complication however the clinical and radiological effects are not seen until weeks or even months) No clinical feature of avascular necrosis but if there is a failure to unite or bone collapse-pain A B The cardinal X-ray feature – increased bone density in the weightbearing part of the joint(new bone ingrowth in necrotic segment) Treatment: Avascular necrosis can be prevented by early reduction of susceptible fractures and dislocations. Arthroplasty - Old people with necrosis of the femoral head. Realignment osteotomy or arthrodesis - for younger people with necrosis of the femoral head Symptomatic treatment for scaphoid or talus Late 5: OSTEOARTHRITIS A fracture-joint may damage the articular cartilage and give rise to post traumatic osteoarthritis within a period of months. Even if the cartilage heals, irregularity of the joint surface may cause localized stress and so predispose to secondary osteoarthritis years later Late 6: JOINT STIFFNESS Commonly occur at the joints close to malunion or bone loss eg: knee, elbow, shoulder Causes of joint stiffness haemarthrosis → lead to synovial adhesion oedema and fibrosis adhesion of the soft tissues Worsen by prolong immobilization Treatment prevented with exercise physiotherapy THANK YOU!!!!
