Introduction in Fracture & orthopedics
Orthopedics concerns with bones, joints, muscles, tendon & nerves i.e. skeletal system & all
that make it move.
Diagnosis begins with systematic gathering of information from history, physical examination,
X-ray & special investigations.
Symptoms:
History can be very informative as examination or laboratory tests.
Orthopedic symptoms can be:
1. Pain.
2. 2. Stiffness.
3. Swelling.
4. Deformity.
5. Change in sensation.
6. Loss of function.
Pain:
Is the commonest symptom in orthopedics if its from or near the skin its well localized to that
site but sometimes its referred pain which means pain that arise from deeper areas & felt far from
its origin e.g. hip pain can be felt in the knee. Always ask the patient to point to the site of pain.
Stiffness:
Defined as limitation of joint movement, it can be generalized as in rheumatoid arthritis or
localized to one joint.
Locking is different from stiffness its sudden inability to complete a movement due to
mechanical block e.g. loose body inside the joint.
Swelling:
It can be in the soft tissue or bone. We must ask whether it occurred after injury or not, is it
rapidly increasing in size or slowly, is it painful or not or if its constant or comes & goes.
Deformity:
Its abnormality in shape, size or direction. It can be congenital or acquired sometimes it
disappears spontaneously or it’s progressive which can be serious.
Change in sensibility:
It can be in form parasthesia, numbness or tingling sensation due to interference in nerve
function in form of local pressure of nerve, local ischemia of nerve or peripheral neuropathy.
On examination we should be able to distinguish between peripheral nerve injury or nerve root
injury.
Loss of function:
As a result of some pathology the patient can’t perform some function e.g. patient say I can’t
stand or sit, I can’t write or open a door or I’m unable to put on my clothes. These can be more
important for the patient than pain or deformity.
Examination:
In orthopedics examination is part of general patient exam or assessment. We examine patient in
3 steps: look, feel & move.
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Look:
Look for skin, shape and position.
• Skin can show scars or color changes.
• Shape can show swelling, wasting or lump.
• Position e.g. some joint or nerve disorder can show characteristic deformities.
Feel:
Feel for skin, soft tissue, bone and joints.
• Skin can be cold, warm, and moist or show sensory disturbances.
• Soft tissue can show e.g. a lump or we can assess the pulse.
• Bone & joint outlines can be examined also we may assess synovial membrane thickening or
increased joint fluid.
• Tenderness is very important sign and if it’s localized its usually diagnostic (if you know
where it is you can tell what it is).
Move:
The joint movement can be; passive, active or abnormal. Active movement we ask the patient
to move the joint and we examine the range of motion & power.
Passive movement we do it to notice the tenderness or abnormal range of movement.
Abnormal movements are those, which does not exist in normal people e.g. due to joint
instability or after fracture.
Always assess the NEUROVASCULAR status of the part or limb.
Swellings:
For those swellings we look for size, site, shape, tenderness, consistency, multiplicity, relation
to nearby structures, mobility and distal neurovascular function.
X-ray examination:
It’s one vital way of diagnosis in orthopedics, it must be done properly with the use of
traditional & special views there should be good technique & done by professional people.
To be informative x-ray should follow the role of two (2):
1. At least two views AP & lateral.
2. Shows two joints one above & one below the area of examination.
3. Show two limbs for comparison.
4. Show the two bones in the forearm & leg.
5. Taken at two different occasions to diagnose the disease and follow its progression.
Special imaging techniques:
1. Contrast radiography: we use opaque liquids to outline sinuses, arthrography to outline
a joint or myelography to outline spinal canal.
2. Tomography: give us a view focused in certain plain only.
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3. CT scan: its able to record bone & soft tissues in cross sections, its important to show
tumor extension & shape in bone & soft tissue also its important for assessment of spinal
canal. Newly there is the spiral CT scan that can give accurate three-dimensional views
of bone & soft tissues in different planes and directions.
4. Radioisotope scan: by injecting the patient with an isotope that can be attached and
concentrated on the site of pathology as tumor, infection or fracture & then we assess the
skeleton for radioactivity to identify the site of pathology in all the skeleton.
5. Ultrasound: for a tissue that does not show in x-ray e.g. soft tissue mass, heamatoma,
cysts, cartilage or joint effusion.
6. MRI: it depends on the response of atoms & molecules to a huge MAGNATIC field.
MRI images are similar but more informative than CT scan, it gives clear differentiation
of tissues & the section can be obtained in almost any plane. It’s most useful for the
brain, spine & spinal cord.
Electrodiagnosis:
It’s called the EMG (electromyography) NCS (nerve conduction study) useful to study the
nerve & muscle function by electrical methods.
Orthopedic procedures
Basic procedures:
1. Drilling: may be used to evacuate a bone abscess & most commonly drill is used to
prepare a hole in the bone for screw.
2. Cutting: cancellus bone can be cut by the osteotome while cortical bone cut by an
oscillating saw.
3. Modeling or reshaping bone: by a chisel or gouge.
4. Reaming meaning widening usually of medullary cavities of bone to allow introduction
of nail or prosthesis.
5. Fixing: bone fragments can be firmly joined or fixed by; screw, plate and screw, long
nails, wires, external fixator or others.
Bony operations
1. Osteotomy: it’s the procedure where we cut bone by osteotome or saw to correct
deformity or reshape the bone or to relieve pain of arthritis. After osteotomy we can fix
the bone by different fixation methods or by POP.
The bone cuts are different e.g. transverse, oblique, wedge like osteotomies (open wedge or
closed wedge sometimes-double wedge).
2. Bone graft: by taking bone from one site of body and putting it in a new site it acts by
two ways;
They replace lost or missed bone. They stimulate new bone formation.
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Bone graft can be of cancellus bone most usually taken from iliac crest or proximal tibia. Or
its cortical bone piece e.g. fragments of fibula or sometimes its mixed corticocancellus graft.
The graft usually taken from the patient himself and called AUTOG RAFT.
Grafts can be from one individual to anther of the same species & called ALLOGRAFT.
3. Fixation of fracture or osteotomy: this can be external or Internal fixation.
Internal fixation by screws, plate and screws, nails, wires. . Etc. directly introduced on the
bone during operation after bone exposure.
External fixation usually used for open compound fractures where there is high incidence of
infection. We use long pins applied from outside through the skin to fix the bone away from
the site of injury proximally & distally & those pins are connected from outside (without
exposure of the wound or fracture) by long bars.
4. Leg equalization: Used for leg length discrepancy; shortening of less than 2cm can be
compensated by the body, but 2-4cm shortening needs shoe raise, while shortening of
4cm and more needs surgical treatment by bone lengthening procedures. Here we do
operation & expose the cancellus bone & we do corticotomy (to cut the outer cortex only)
& we put external fixator & close the wound. Few days later we start to do distraction of
the fixator & bone (lengthening) this is done daily in term of 1mm per day until the
desired length is attended then we stop lengthening and allow the bone gap to heal for the
next 6-12 weeks.
Operations on joints
1. Arthroscopy: the interior of a joint can be visualized by inserting an endoscope through a
small incision. In addition introducing certain instruments through separate portals can do
certain operative procedures.
2. Arthrotomy: it means surgical opening of a joint, its indications are:
a) To inspect the inside of the joint or taking synovial biopsy.
b) To drain heamatoma or abscess.
c) To remove loose bodies or damaged structures like torn meniscus.
d) To excise inflamed synovium (synovectomy).
3. Realignment osteotomy: used for the treatment of mild osteoarthritis in young patients.
We do osteotomy near the affected joint & realign articular surfaces so that the less affected
sides exposed to the maximum weight bearing stresses. Usually the osteotomy is held by
internal fixation.
4. Arthrodesis: it means fusion of the joint in functional position used for destroyed painful
or unstable joint. There must be good functioning proximal & distal joints & the principle
of surgical procedure is:
a)Removal of both joint surfaces & exposure of underlying bone.
b) The bones are apposed together in a functional position & fixing it by internal fixation.
c) Bone graft is added to improve & hasten fusion.
d) The limb is splinted for 3-6 months until joint fusion & union.
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5. Arthroplasty: these operations aim at pain relief & improvement of range of
movement. There are 3 different types:
a) Excesional arthroplasty: we excise good amount of bone & create a gap instead of the
joint which later get fibrosed & allow good painless range of motion but the joint gets
unstable e.g. hip excesional arthroplasty which is called Girdle-stone hip arthroplasty.
b) Partial replacement arthroplasty: here only one joint surface is cut & replaced by a
prosthesis which is fixed to bone by fitting or bone cement e.g. Austin-Moore
hemiarthroplasty for fracture of femoral neck.
c) Total joint replacement arthroplasty: as for the knee or hip. Here both articular surfaces
are cut and replaced by prosthesis that is fitted to the bone or fixed to it by bone cement.
Amputations
It means excision of limb at a certain point; the indications are summarized by 3D.s:
Dead (or dying), Dangerous & Damn nuisance.
• Dead as due to gangrene following vascular ischemia or trauma or frostbite.
• Dangerous as the limb is having serious malignant tumor or lethal infection as gas gangrene.
• Damn nuisance its means the limb is worse than no limb at all because of pain, gross
deformity, frequent sepsis or severe loss of function.
Site of amputation (where to do amputation):
With the advances of prosthetic appliances amputation can be performed at any point, but the
choice now depends on the site where the amputation wound can heal & this depends on the
circulation & the pathology. e.g. peripheral vascular ischemia can show at the toes but we do
below knee amputation just below the distal palpable pulse. While in young healthy patients
who had severe trauma we do amputation as distal as possible where a skin cover is available for
the wound.
Prosthetic fitting of amputated limb:
This is always available & must be applied soon after operation it should be comfortable, well
fitted & allow acceptable function.
Complications of amputation:
In addition to the complications of any operation, amputation has specific complications as:
Early:
1. Wound opening or dehiscence this due to ischemia or suturing under tension.
2. Gas gangrene especially in lower limb following vascular ischemia where the clostridium
spores from the perineum may infect the amputation.
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Late:
1. Nerve:
a. Painful neuroma; usually when we cut the nerve at the site of amputation, it gets swollen
& forms a bulb giving a tender and painful neuroma that may need excision.
b. Phantom phenomenon; it’s the feeling that the removed amputated limb is still present. It
needs good patient education before & after surgery & good sedation it usually gradually
disappear.
2. Artery: poor circulation gives blue cold stump liable to ulcerate & may need re-amputation.
This complication arises from wrong choice of amputation site.
Common amputations are:
Toe amp., midfoot amp., Syme’s amp., below knee amp., through knee amp., above knee amp.
& disarticulation through hip. Same in the upper limb.
Post-operative complications in orthopedics
There are complications that are specific to each orthopedic surgery but common
complications that can occur in every surgery can be:
1. Soft tissue swelling;
Its common after limb surgery its aggravated by tight dressing or POP it may affect
wound healing & delay joint movement sometimes its so serious causing vascular ischemia &
compartment syndrome. Prevention is by;
a. Dressing must not be tight.
b. Elevation of the limb.
c. Encourage early joint movement.
d. POP cast must be well padded & not tight.
2. Heamatoma formation;
By post-operative bleeding or ooze sometimes it’s considerable. It’s reduced by using
suction drain.
3. Delayed wound healing;
Usually due to poor circulation.
4. Infection;
It’s seriously disturbing especially in joint replacement surgery.
5. Thromboembolism;
The incidence of DVT is 20%, only 2% gets pulmonary embolism and only
0.2% will die of it.
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Highest incidence in hip surgery especially in old debilitated patient.
The commonest type of DVT is that occurring in calf vein which carry better prognosis than
that in proximal thigh vein thrombosis.
Clinical features:
DVT usually silent, if it’s manifested it may cause calf or thigh pain sometimes swelling &
local tenderness.
In calf vein thrombosis there will be positive Homan’s sign i.e. increased calf pain on passive
dorsiflexion of the foot. Sudden slight increase in temperature may occur.
If pulmonary embolism occurs patient may have shortness in breath, mild chest pain &
sometimes heamoptysis, rarely sudden severe cardiovascular collapse & death.
Investigations:
Doppler U/S can prove the diagnosis. More accurate is ascending veinogreaphy.
In pulmonary embolism ECG changes may happen.
Prevention:
• Pre-operative; by decrease smoking, walking exercises, treatment of systemic diseases &
calf muscle massage with preoperative Heparin 5000 IU twice daily for high risk patients.
Recently we can use low molecular weight heparin.
• Per-operative; avoid trauma to calf veins & frequent massage or use of special elastic stokes.
• Post-operative; calf muscle massage, elastic stokes, early active movement & ambulation,
leg elevation together with few days of subcutaneous heparin therapy.
Treatment:
Calf vein DVT treated by heparin 5000 IU s.c. For 10-14 days then change to oral
warfarin 5mg once daily for 2-3 months (all under strict supervision by the doctor with
frequent PT & PTT check).
Thigh or proximal vein thrombosis is more serious it needs full heparin therapy of 5000
IU four times daily intravenously 1-2 weeks followed by 5mg warfarin orally for 3-6 months
(all under strict supervision by the doctor with frequent PT & PTT check).
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Physiotherapy
It’s used to:
1. Reduce pain.
2. Increase range of motion.
3. Strengthen muscles.
4. Restore function.
All achieved by;
1. Heat; its useful to reduce pain & muscle spasm.
2. Cold; like ice packs it decreases pain & reduces swelling.
3. Transcutaneous nerve stimulation; also relieves pain.
4. Traction; intermittent traction of the spine can relieve neck pain or low back pain.
5. Electrical stimulation & muscle exercises; it builds up muscles & improves weakness.
Occupational therapy
Its used to improve function i.e. teaching the patient to use his skeleton & muscles to perform
useful daily activities as feeding, hygiene, walking. .Etc.
Functional aids
These are used to decrease stresses on musculoskeletal system during weight bearing like:
stick, cane, crutches or frame. During weight bearing these patient uses these to decrease the
mechanical stresses passing through his joints & bones.
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Fractures-general principles
A fracture is an interruption in the bone continuity caused usually by strong trauma in healthy
bones (traumatic fracture).
Pathological fracture is that which occurs after simple trauma in an abnormally weak bone as in
tumors or infection.
Stress fr. is that one which occurs in a healthy bone in a form of simple crack following multiple
frequent simple trauma or stress.
Simple or closed fr. Are those with intact skin and not contaminated.
Compound or open fr. Are those with localized wound over the fr. They carry high incidence of
infection and carry worse prognosis in comparison with closed fr.
Fr. can be complete involving both bone cortices and separating fragments.
Fr. can be incomplete or partial fr. where only single cortex is involved and there is no
displacement as in green-stick fr. of young children.
There may be single fracture line with two segments and the fr line can be transverse, oblique or
spiral.
There may be multiple fr. Lines near to each other in the same bone giving multiple fragments
and the fr. Called comminuted fr.
Segmental fr. is when the bone has two different fr. Lines away from each other separating an
intact bone segment.
Intra-articular fr. Is that occurring at a bone end where the fr. Line extend to the joint, it carry a
poor prognosis regarding later joint osteoarthritis.
Mechanism of fr.:
1. Direct trauma: the bone usually breaks at point of impact.
2. Indirect trauma: as angulation or rotation or compression of the limb, this can cause fr.
Away from the site of injury.
3. Multiple or complex injury of different forces at the same time that may cause serious
complex fracture.
4. Muscle violence: sudden strong muscle pull on the localized bony attachment may cause
(avulsion fr) of the bony fragment with or without displacement, eg. Quadriceps pull on
the patella cause transverse fr, triceps pull on the olecranon causes avulsion fr of
olecranon.
Fracture displacement:
Fr may be undisplaced or usually displaced according to the; type of injury and the direction of
ft line also depends on localized muscle action and gravity, displacement described according to
the direction of the distal segment, this can be in form of;
1. Overlap.
2. Side displacement.
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3. Angulation.
4. Rotation.
Fracture healing or union:
Bone is one of the unique tissues in the body that heals or replaced after loss by (same tissue)
the bone.
When there is a gap and if the segments still have some movement healing is by CALLUS
formation it pass in five stages (gap union):
1. Tissue death and heamatoma formation:
Local bony necrosis will occur about 1 to 2 mm back from the fracture line and capillary
bleeding will lead to localized fr heamatoma that bridges the fr and later clots.
2. Inflammation and cellular proliferation:
Within 8 hours there will be acute inflammatory cell reaction, within few days there is
chronic inflammatory cell accumulation. This later will lead to local granulation tissue
formation after capillary growth; cellular proliferation will take place as well.
3. Callus formation:
Proliferating cells will show variable chondrogenic and osteogenic activities with
subsequent cartilage and finally bone tissue formation that will later replaces the whole
granulation tissue mass leading to a big irregularly laid fusiform bony mass called the
CALLUS that bridges the fr and locally fix it, the fr now is united but its not healed yet.
4. Consolidation stage:
Here the callus is gradually replaced by physiologically normal solid bone that will cross
through the fr line and fill the gap, the fusiforrn callus replaced by variable osteoclastic
(bone resorbing) and osteoblastic (bone forming) cellular activity, the newly laid solid bone
is of near normal shape and can take normal forces and loading.
5. Remodeling stage
Gradual bone resorbtion and new bone formation will occur where the solid deformed
bone is replaced by new normal bone that takes the original bone shape with reformation of
the medullary canal, this may take months or even years to occur.
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Anther type of bone healing is that which is called PRIMARY VASCULRE UNION
OR HEALING; it occurs when the fr fragments are accurately reduced and rigidly
immobilized where direct capillary growth and new bone laid across the fr line (without
callus) as in primary healing of the skin.
Sometimes healing with callus formation is described as secondary healing as in skin healing.
Factors affect and help bone healing may be:
1. Proper contact and apposition of fr fragments.
2. Good local blood supply.
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3. Adequate immobility or fixation of the fr.
4. Absence of infection.
5. Early and good management.
Diagnosis of fr:
Diagnosis of fr is both clinical and radiological.
Clinical diagnosis;
1. There is history of injury or trauma.
2. Patient has pain.
3. Inability to move or use of the limb (loss of function).
By local examination there is:
1. Local tenderness.
2. Swelling by heamatoma or soft tissue edema.
3. Deformity, the limb may acquire an abnormal posture like abnormal angulation,
rotation... etc
4. Abnormal movements can occur at the fr site when it’s complete fr.
5. CREPITUS its characteristic of fr where an abnormal friction sound can be elicited
between the fr fragments when they are moved.
Radiological diagnosis;
The fr line can be shown by a good x-ray exam specially with application of the role of two,
the fr line can be seen and we can describe the fr site, shape and displacement exactly.
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problems of union:
Sometimes bone healing is delayed and takes more than usual time here we call it DELAYED
UNION.
Sometimes the fracture fail to unite and the problem is called NON-UNION, this can be
atrophic non-union where bone completely fail to form around the fracture,
or its called hypertrophic non-union where there is excessive large callus that cannot pass
through the fr line and bridge the fr fragments.
Causes of non-union can be
1. Wide separation of fr fragments.
2. Soft tissue interposition between the fragments.
3. Poor local blood supply.
4. Excessive movement of the fr fragments.
5. Local infection as in compound fracture or after surgical operation.
6. Continuous pull of the fragments by a muscle as in avulsion fr of patella or olecranon.
7. Delayed or poor management.
8. In debilitated, elderly or sometimes chronically diseased patients.
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Clinical symptoms and signs of non-union are nearly the same as for fractures unless at later
stages the gap is filled with fibrous tissue (fibrous union) and the fracture area becomes painless
with the presence of abnormal movements (pseudoarthrosis = false joint).
Radiologically atrophic nonunion shows;
1. Maintenance of the fr line.
2. Resorbtion of the ft end that will show a rounded appearance rather than the sharp fr
ends.
3. Local sclerosis of the fr ends.
4. Sometimes abnormal position or displacement of the fragments.
Hypertrophic non-union gives the radiological appearance of maintenance of the fr line
with extensive callus proximal and distal to it, also abnormal position of the fragments may be
seen. The appearance sometimes refereed to as elephant foot or hours hoof appearance.
Sometimes bone unites in an abnormal position, this is called MAL-UNION, this can lead to
various deformities and functional impairments.
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MANEGMENT OF CLOSED FRACTURES
We must always think of possible associated injuries of the patient so we must examine
the patient as a whole and do the urgent resuscitation or treatment before we think of the
fracture.
The golden rule is TREAT THE PATIENT AND NOT SIMPLY THE PART.
The two main procedures in treating closed fr are:
1. Reduce the fr to normal or near normal position, this can be
Closed reduction by manipulation of the fr under anesthesia or sometimes
analgesia; this includes:
a. Traction of the fragments (always use a counter traction of the assistant) to
disimpact the fr.
b. Move the distal segment in a way to reverse the mechanism of injury so that we
can get proper realignment of the displaced fragments.
Reduction can be open reduction through surgical operation this is done in cases
of failure of closed reduction or in special occasions when closed reduction is not useful
or not applicable, it’s also preferred for intraarticular fr.
2. Hold the reduction in the proper position for a suitable period to allow union; this can be
achieved by variable ways:
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a. Cast immobilization: by using the plaster of Paris (POP) where we try to immobilize the
reduced fr in position together with a proximal and a distal joint to ensure maintained
reduction, this takes longer time and cause stiffness of the involved joints and it has other
complications as well but still a very good choice for certain fr specially in young and in the
upper limb.
b. Maintained traction: this can be a skin traction by using certain plaster and bandages and
using weights to pull the distal fr segment against a counter traction force that can be a fixed
point of the body and its called fixed traction, or the counterforce can be mobile one depending
for example on body weight or gravity and here its called balanced traction.
Or the above tractions can be skeletal tractions where the plaster and bandage is replaced by
metal pins passed through bone and we apply the weight of traction on it.
c. Interna1 fixation: its usually done after open reduction by which we hold the reduced
fragments by variable types of endoprosthesis that is usually made of stainless steel or other
inert rigid metals, this can be a screw, plate and scews, intramedullary nails, angled implants
like dynamic hip or condylar screws... etc
The indications of open reduction and internal fixation (ORIF) are:
1. Fractures that cannot be reduced only by operation.
2. Failure of conservative treatment.
3. Unstable fr that frequently redisplaces after closed reduction e.g. fr of forearm or mid
shaft of femur.
4. Fr that poorly heals and takes long time to do so in conservative way e.g. femoral neck fr.
5. Pathological fractures.
6. Polytraumatized patient with multiple fr.
7. Patients that have nursing difficulties as in elderly, paraplegics, chronically diseased...etc
8. Fr with vascular injury that needs surgical intervention.
d. External fixation: its usually used in compound fr it means that we use a metal pins that pass
through the skin from outside proximal and distal to the fr and after proper reduction the pins are
joined together outside the skin by special long bars.
The indications of external fixation:
1. Compound fractures.
2. Infected fractures as after internal fixation.
3. Multiple fractures, as an urgent way to stabilize a seriously ill patient.
4. Fr with nerve or vessel injury.
5. Fr with extensive soft tissue damage.
6. Fr of pelvis.
7. Seriously comminuted and unstable fr.
8. For bone lengthening.
9. For joint arthrodesis.
The treatment of closed fr always includes physiotherapy, exercises and rehabilitation.
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Management of open fractures
Open fr are those associated with wounds over them they carry high incidence of infection,
usually caused by sever trauma and the patient may be multiply injured i.e. there may be other
associated fr and other system injury e.g. head, abdomen, chest... etc.
For open ft certain important things must be remembered:
1. There may be sever shock.
2. Bleeding may be serious.
3. High risk of pyogenic infection, tetanus and gas gangrene.
4. Fracture healing is difficult and usually delayed.
5. There is a severe soft tissue damage and possible muscle, nerve or vessel injury.
Management:
A. In multiple injured patients the basic priorities is to be followed; the ABCDE
A. Airway clearance.
B. Breathing control.
C. Circulation and hemorrhage control.
D. Disability—neurological status.
E. Exposure of the whole body to assess injuries.
All above done at the same time and a good multiple venous access secured for patient
resuscitation and replacement.
System priorities we care to vital systems according to importance for life according to this
sequence:
1. Head injury.
2. Chest injury
3. Abdominal and pelvic visceral injury.
4. Skeletal injuries i.e. bonny fr and dislocation which can be multiple as well. Those
injuries can be closed or open.
B.
For open fr the definitive treatment: includes first aids and operation
first aid treatment
1. Patient clothes are removed, limbs are washed and wounds are sterilized and dressed.
2. Temporary splintage (immobilization by splints) of fractured limbs
3. At the same time SHOCK is treated and patient is resuscitated and replaced with blood,
fluids.. .etc to stabilize his general condition.
4. Anti tetanus prophylaxis.
5. Anti gas gangrene prophylaxis.
6. Combined prophylactic antibiotic treatment until results of culture and sensitivity show the
specific antibiotics to be used.
7. Prepare the patient for urgent anesthesia and surgery.
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Operation (wound excision or called debridemcnt)
1. Patient must take general anesthesia.
2. Tourniquet must be used when needed.
3. Skin must be prepared.. i.e, hair is shaved, skin around the wound is washed very well,
wound sterilization.
4. The surgical procedure is called wound debridemcnt, which is the technique that
include exploration of the wound, excision of dead devitalized tissue, and removal of
foreign material.
5. Open reduction of the fr and fixing the fracture with external fixator.
Debridement starts from the skin down to the bone:
 Skin is excised few millimeters away from the wound until regular healthy wound
margin is gained.
 Deep fascia if dead is removed widely and extensively opened all through the
wound and beyond its limits as well.
 Foreign and dirty materials are carefully removed from the wound and proper
wound cleaning and sterilization is achieved.
 Muscles which are dead removed until healthy muscle is reached, doubtful
muscles are examined well, normal muscle looks pink while dead muscle looks
darker, healthy muscle have bleeding margin but dead muscle does not bleed, and
viable muscle contracts when stimulated as by an artery or other tool during
operation but it dose not contract when dead,
 Nerves and tendons are dealt with carefully, in the early treatment we usually
don’t do immediate repair, we try to clean and minimally cut the dead damaged
edges. We approximate the two ends by a black silk suture that will act as marker
in later explorations when we do secondary suture or repair.
 The fractured bone is gently displaced and the bone ends are cleaned with a
curette and washed then we replace it back in normal position and alignment
(open reduction). Any small fragment that has a soft tissue or periosteal
attachment that ensures blood supply must be preserved. Very small segments that
are completely displaced and have no attachment can be removed with
precautions.
 Fractures then stabilized by external fixation until there is good skin cover or
until union.
 The wound must left open to avoid serious infections and other
complications.we use sterile packing and dressings.
 Wounds usually re-explored 5-7 days later and anther debridement is done, this
is repeated until we decide wound closure.
 Wound closure varies according to the degree of primary skin damage and loss.
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Sometimes we do delayed primary suture, or secondary suture, if the defect is
large it may need a graft that can be a simple skin graft or even a combined
fasciocutaneous, myocutaneous or other grafts all depends on the degree of skin
loss.
 Before, during and after surgery we should use specific antibiotics according to
frequent wound swab cultures; also we support the patient general health and
condition.
 Physiotherapy and muscle exercises with rehabilitation are all part of the
treatment.
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Complications of fractures
Those can be:
I. General.
2. Local.
General complications
1. Hemorrhage and shock.
2. Fat embolism.
3. Venous thrombosis and pulmonary embolism.
4. Crush syndrome.
5. Complications of prolonged bed rest and recumbancy, especially in elderly and aged
patients. . e.g. DVT, bedsores, hydrostatic pneumonia and UTI.
Local complications
Those can be early or late;
Early local complications includes:
1. Infection.
2. Vascular injury.
3. Nerve injury.
4. Visceral injury.
5. Heamarthrosis (bleeding inside a joint).
6. Compartment syndrome.
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Late local complications includes:
1. Delayed union and nonunion, those may need surgical treatment with Refreshment of the
bony ends, Re-reduction of the fr. Reinforcement by rigid internal fixation and
Replacement by bone graft (the four R principles).
2. Mal-union, if its sever and affect function or show severe deformity it may need surgery in
form of Osteotomy at site of deformity, Reduction to normal position, Internal fixation
and sometimes Bone graft.
3. Joint stiffness, this needs good physiotherapy and exercises and sometimes manipulation
or even surgical soft tissue release.
4. Myositis ossificans around a joint or of the muscles which causes sever stiffness and it’s
difficult to treat.
5. Algodystrofy or reflex sympathetic dystrophy where the limb get swollen and painful with
excessive loss of bone mass and functional disturbances, this usually treated with
physiotherapy and exercises with symptomatic treatment but still it can be sever and very
disturbing and difficult to treat.
6. Avascular necrosis of nearby bony end or segment, this occurs in certain regions where the
blood supply of a bony end (usually inside a joint) is critical and seriously affected by the
fr. this leads to serious changes which may ends in damage to nearby joint and serious
functional deficit.
7. Osteoarthritis, it’s a degenerative joint disease associated with pain and limitation of
movement.
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Special features of fractures in children
There are two main issues
1. Green stick (incomplete) fractures:
Children with their growing bones that have high elasticity can withstand deforming forces
without fracture because of the ability of bone to bent to a certain degree, if the force is greater
the bent bone may fracture on the concave stretched side and still intact on the opposite side like
in bending a green stick, those fr are stable and heals rapidly with beast prognosis.
2. Epiphysial injuries.
The children bones grow on their ends through an Epiphysial plate (also called physis) that
lay down new bone in both directions;
Bone formed towards the joint and that part called the epiphysis.
Bone formed towards the shaft that part called the metaphysis.
The shaft itself called the diaphysis.
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The epiphysial plate appear radiolucent on x-ray because they are mainly of cartilage tissue,
this growing plate will stop growing and gradually ossify and disappear around the time of
skeletal maturity, each plate disappear at different time during life.
Injuries and fractures at the region of epiphyseal plate carry the bad and serious complication
of disturbing or stopping bone growth of all or part of the Epiphysial plate giving rise to later
shortness or deformities of the involved limb or joint.
Those fractures around the physis are classified according to SALTER-HARRIS
classification into:
Type1; the fracture pass through the Epiphysial plate only and there is no displacement.
Type 2; fr line pass through most of the epiphysis and cuts partly on the metaphysis displacing
the epiphysis and the attached small metapliyesial triangular segment.
Type 3; partial epiphysial plate fracture that will continue through the epiphysis separating
epiphysial fragment.
Type 4; the fracture line cuts through the epiphysis and the metaphysis separating an epiphysial
fragment with its opposed epiphysial plate and metaphysis.
Type 5; its compression fr of the epiphysis that does not usually seen in x-ray. It carries the
worst prognosis, as it’s commonly lead to growth disturbances.
Type 1 and 2 are commoner and carry good prognosis, while type 3 and 4 are less common and
carry poorer prognosis.
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JOINT INJURIES
Joints may also get injured after trauma and this may lead to variable degrees of soft tissue
injuries of the capsule, ligaments or other intraarticular structures like menisci, also there may be
some degree of displacement of the opposing articular surfaces leading to joint subluxation or
dislocation.
Joint dislocation: it’s the condition of complete displacement of articular surfaces.
Joint subluxation: it’s the condition of incomplete (partial) displacement of articular surfaces.
Joint subluxation or dislocation is a medical emergency, where we need to do joint reduction
as soon as possible to avoid possible future complications as chronic joint instability or
osteoarthritis.
Displaced joints after trauma are usually reduced under anesthesia (manipulation under
anesthesia MUA) and rested for 2-3 weeks with pop to allow soft tissue healing, this is followed
by good course of physiotherapy to regain muscle power and joint motion.
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Volkman’s ischemia (compartment syndrome)
Its defined as the process of increased soft tissue pressure within enclosed compartment
that leads to failure of capillary circulation causing tissue ischemia and damage.
The problem is not a major vascular impairment it starts as failure of capillary circulation.
Enclosed compartment are those where the soft tissues does not allowed to enlarge or
swollen in case of increased tissue pressure, as in case of tight osteofascial compartments of the
forearm or leg where the tight fascia dose not allow excessive tissue swelling.
Also tight compartments occurs when we put POP cast around an acutely injured limb or
immediately after operations of the limb where progressive tissue swelling will be prevented by
the POP compartment leading to increased tissue pressure and ischemia. For that reason after
acute injuries or operations we usually use POP back-slab i.e. the POP is only in one side of the
limb and other side wrapped with cotton-wool and bandage to allow local swelling without
increased pressure.
Soft tissue swelling may occur after direct injury and this may lead to compartment
syndrome.
Direct or partial vascular injury and insufficiency also causes tissue ischemia and later
swelling leading to increase tissue pressure and subsequent compartment syndrome.
Pathology and pathogenesis:
The compartment syndrome is a serious condition because it leads to a VICIOUS CIRCLE
where tissue ischemia causes soft tissue swelling and as the swelling occurs and increase in a
closed compartment there further increase in local tissue pressure until its more than local
capillary pressure causing failure of capillary circulation with hypoxia and lactic acidosis that
cause further edema and further increase in tissue pressure with further ischemia . . . and so on.
The ischemia will cause tissue death; the most sensitive tissues affected are the nerves and the
muscles that will die. After control of the compartment syndrome the nerves can regenerate and
regain some or all of its function but not the muscles that after ischemia and death will heal with
fibrous tissue that will contracts later giving a chronically deformed limb with serious functional
impairment (the Volkman’s contracture).
Clinical features:
There are FIVE cardinal clinical features of compartment syndrome they are the FIVE Ps:
1. Painful limb (pain is much greater than expected from the injury itself despite good
management) or sometimes the limb is tender to stretch because of tender muscles.
2. Pale or plum colored skin, sometimes its cyanosed skin.
3. Parasthesia due to disturbed nerve function.
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4. Paralysis or weakness due to muscle ischemia.
5. Pulseless limb, only at late stage after serious pressure increase with impairment of
major vessel circulation, PRESENCE OF PULSE DOES NOT EXCLUDE
COMPARTMENT SYNDROME, it’s a crime to wait until the pulse is absent.
Diagnosis must be made at earlier stages, and it’s not important to have all the signs and
a symptom to say there is a compartment syndrome. For example we must keep it in mind
after any possible cause of compartment syndrome and frequently look for it, as limb is in
sever unexpected pain with local muscle tenderness on stretch or if skin gets pale or dusky
we must check for compartment syndrome and this is done very simply by measuring the
local tissue pressure and if its more than 40mm Hg it means there is compartment syndrome
that needs management, sometimes we do continues tissue pressure monitoring for expected
compartments.
Management of compartment syndrome:
The primary cause must, must, and must be removed if possible e.g. removal of tight POP cast,
bandages or dressings. Control of main vessel insufficiency, and measure the pressure. If it’s
present and there is no relief THE CLOSED COMPARTMENT MUST BE OPENED by
surgical FASCIOTOMY by opening of the tight deep fasciae all over the closed compartment
to decrease the local pressure and break the circle of progressive tissue death and improve
capillary circulation.
Fascitomy is an urgent simple surgical procedure that can save a limb from serious
consequences as deformity and functional losses.
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