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How to Treat Bone Injuries

How to Treat Bone Injuries

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Published by Surgicalgown
Musculoskeletal injuries comprise over one third of all trauma. That is why orthopaedic injuries occupy a sizeable part of this text.
Fractures are described according to (Fig. 13.1):
• which bone
• which part of that bone (proximal, middle, distal)
• fracture pattern/direction (oblique/spiral, transverse (pathological), segmental or comminuted).
• then displacement/alignment of the position of distal fragment as tilt (angulation), shift (% end-to-end contact) and twist (rotation - maybe hard to assess but often important).
• whether nearby joint involved
• associated factors (dislocation, open fractures etc.)

The mechanism of injury is useful to know to assess the "personality" of the fracture and so treatment (e.g. compression forces result in angulated or T-type fractures; rotational forces in spiral fractures; traction injuries in avulsion fractures).

Essential orthopaedic references include:
• WorldSurg, www.worldsurg.com
• Wheeless' Textbook of Orthopaedics, www.medmedia.com
• Manual of Internal Fixation
• Principles of Fractures and their Treatment
Musculoskeletal injuries comprise over one third of all trauma. That is why orthopaedic injuries occupy a sizeable part of this text.
Fractures are described according to (Fig. 13.1):
• which bone
• which part of that bone (proximal, middle, distal)
• fracture pattern/direction (oblique/spiral, transverse (pathological), segmental or comminuted).
• then displacement/alignment of the position of distal fragment as tilt (angulation), shift (% end-to-end contact) and twist (rotation - maybe hard to assess but often important).
• whether nearby joint involved
• associated factors (dislocation, open fractures etc.)

The mechanism of injury is useful to know to assess the "personality" of the fracture and so treatment (e.g. compression forces result in angulated or T-type fractures; rotational forces in spiral fractures; traction injuries in avulsion fractures).

Essential orthopaedic references include:
• WorldSurg, www.worldsurg.com
• Wheeless' Textbook of Orthopaedics, www.medmedia.com
• Manual of Internal Fixation
• Principles of Fractures and their Treatment

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Published by: Surgicalgown on Jun 06, 2009
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02/03/2013

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Introduction
Musculoskeletal injuries comprise over one third of all trauma. That is why orthopaedic injuries occupy a sizeable partof this text.Fractures are described according to (Fig. 13.1):
which bone
which part of that bone (proximal, middle, distal)
fracture pattern/direction (oblique/spiral, transverse (pathological), segmental or comminuted).
then displacement/alignment of the position of distal fragment as tilt (angulation), shift (% end-to-endcontact) and twist (rotation - maybe hard to assess but often important).
whether nearby joint involved
associated factors (dislocation, open fractures etc.)The mechanism of injury is useful to know to assess the "personality" of the fracture and so treatment (e.g.compression forces result in angulated or T-type fractures; rotational forces in spiral fractures; traction injuries inavulsion fractures).Essential orthopaedic references include:
WorldSurg, www.worldsurg.com
Wheeless' Textbook of Orthopaedics, www.medmedia.com
Manual of Internal Fixation
Principles of Fractures and their Treatment
Open fractures
These fractures communicate with the skin and should be handled with extreme care as contamination and softtissue disruption may result in disaster. Formal, thorough debridement with irrigation (normal saline), preferablypulsed should be performed within eight hours of injury. Otherwise serious infection may result.The basic steps to the management of open fractures are:1. Debride the soft tissues and debride the bone.2. Stabilize the soft tissues and stabilize the bone;3. Reconstruct the soft tissues and reconstruct the bone.First or second generation cephalosporin and an aminoglycoside should be given for 48 hours. Use of penicillinshould be considered for barnyard or clostridial infections. Also appropriate immobilization and fixation is required.See Chapter 00. Gunshot wounds are open fractures (see Chapter 00 and appendix 00). The resultant soft tissue disturbance andbone destruction is usually based on the velocity of the bullet. For instance the relative low velocity of handgunscauses the least soft tissue destruction. Treatment usually consists of entry and exit wound debridement. The high
 
velocity of military rifles causes massive soft tissue destruction, which requires stage II debridement of the entiremissile track. Intra-articular bullets should be removed as these may cause lead intoxication. Beware of arterial injury.Signs include diminished pulses and haematoma. An arteriogram should be sought.
Life threatening conditions
A.T.L.S. guidelines should be followed. If these guidelines are applied preventable death has decreased markedly -from 14% to 3%. See Chapter 00Concept of the golden hour The causes of adult trauma include gunshot wounds, road traffic accidents, stabbings, industrial accidents, sport,recreational and domestic accidents. First stabilize - ‘life before limb’. Do not delay surgery but make sure everything is ready and optimal (metabolic and cardiopulmonary status, the teamis available, equipment and your plan). Then - assess the associated bone trauma once the patient is stabilized.
Orthopaedic procedures
X-rays are important to assess bony and soft tissue trauma. Obtain standard AP and lateral x-rays with joints aboveand below the fracture. Appendix 00 shows the full list of x-ray views. For peri-articular fractures, oblique views areuseful. Tomograms (a cross section ‘slice’) are helpful. MRI provides excellent three dimensional images but isexpensive and is best reserved for spinal work. CAT scans are useful for most injuries except spinal, pelvic andcalcaneus. Bone scans will 'find" injuries including stress fractures and are also useful in child abuse screeningReduce the fractureThe inexperienced often agonize over which fractures to reduce, how to reduce them, in what position to hold themand how to hold them. In principle a displaced fractured often needs to be reduced . The best position is the originalanatomic position (if possible). And the best way to hold the reduction is the simplest method (usually plaster of Paris,POP). Having said that there are a lot of difficult fractures (multiple, pathological, open, comminuted, into joint and involvinggrowth plates), under difficult circumstances (war or simply no proper equipment, hospital, staff), with difficult patients(obese, unwell, unreliable, drug addicts).Technique of closed reduction for e.g. Colles fracture (Fig 13.2):Functional bracingAn excellent way of treating selected fractures of the tibia, humerus, ulna developed by Sarmiento (1999), whichallows nearby joints to move. Indications in foot note . 
 
Relative contraindications (1) selected diaphyseal tibial fracture with an intact fibula; fractures in poly-trauma whocannot use an aid to walk; (2) axially unstable fractures with initial shortening >12mm where length has been restoredby traction unless patients are kept from weight bearing for a period of time to allow stability to develop.Humeral shaft fractureFor: closed diaphyseal fractures without marked distraction between fragments; closed fracture associated with radialnerve palsy similar to above; open fractures without significant soft-tissue injury.Relative contraindications: bilateral humeral fractures; polytrauma where not able to ambulate with support.Isolated ulnar fractureFor: isolated shaft fracture without displacement; type 1 &11 open fracture as above; no dislocation of proximalradius; bilateral closed ulnar fracture without polytrauma.Relative contraindications: open fractures with a lot soft tissue injury; where dislocation of radial head
Sarmiento 1999 Functional Fracture Bracing J. AAOS 7 p66-75
Technique to apply tractionSee appendix 00.Reduction maybe closed (manipulate/apply traction or open usually with internal fixation i.e. ORIF). Hold either externally with POP, functional brace, splint , external fixateur or internally with plates, screws, nails. Joint surfaceinvolvement demands near-an-atomic reduction [< 2mm]. Consider age and state of the wound and pre-injuryfunction.ImmobilizationImmobilization decreases movement at the fracture, prevents displacement and relieves pain. Achieved by traction,internal and or external fixation, splinting, functional bracing, casting, orthotics.Preserve functionUltimate goal is rehabilitation. See Chapter 00.
Orthopaedic complications
May result from the injury or other organ systems. Include bone healing problems usually due to limited healingpotential from limited or disturbed blood supply. Caused by infection or inadequate fixation, inadequate blood supply,excessive space between fracture fragments, too much or too little motion at the fracture site, soft tissue interposition,delayed union (where free movement of bone ends >4 months after injury/beginning of treatment), nonunion (freemovement >6 months).

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