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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
Open fractures These fractures communicate with the skin and should be handled with extreme care as contamination and soft tissue disruption may result in disaster. Formal, thorough debridement with irrigation (normal saline), preferably pulsed should be performed within eight hours of injury. Otherwise serious infection may result. The basic steps to the management of open fractures are: 1. 2. 3. Debride the soft tissues and debride the bone. Stabilize the soft tissues and stabilize the bone; Reconstruct the soft tissues and reconstruct the bone.
First or second generation cephalosporin and an aminoglycoside should be given for 48 hours. Use of penicillin should 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 and bone destruction is usually based on the velocity of the bullet. For instance the relative low velocity of handguns causes 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 entire missile 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 00 Concept 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 team is 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 above and below the fracture. Appendix 00 shows the full list of x-ray views. For peri-articular fractures, oblique views are useful. Tomograms (a cross section ‘slice’) are helpful. MRI provides excellent three dimensional images but is expensive and is best reserved for spinal work. CAT scans are useful for most injuries except spinal, pelvic and calcaneus. Bone scans will 'find" injuries including stress fractures and are also useful in child abuse screening
Reduce the fracture The inexperienced often agonize over which fractures to reduce, how to reduce them, in what position to hold them and how to hold them. In principle a displaced fractured often needs to be reduced . The best position is the original anatomic 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 involving growth 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 bracing An excellent way of treating selected fractures of the tibia, humerus, ulna developed by Sarmiento (1999), which allows nearby joints to move. Indications in foot note .
Relative contraindications (1) selected diaphyseal tibial fracture with an intact fibula; fractures in poly-trauma who cannot use an aid to walk; (2) axially unstable fractures with initial shortening >12mm where length has been restored by traction unless patients are kept from weight bearing for a period of time to allow stability to develop. Humeral shaft fracture For: closed diaphyseal fractures without marked distraction between fragments; closed fracture associated with radial nerve 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 fracture For: isolated shaft fracture without displacement; type 1 &11 open fracture as above; no dislocation of proximal radius; 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 traction See 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 surface involvement demands near-an-atomic reduction [< 2mm]. Consider age and state of the wound and pre-injury function. Immobilization Immobilization decreases movement at the fracture, prevents displacement and relieves pain. Achieved by traction, internal and or external fixation, splinting, functional bracing, casting, orthotics. Preserve function Ultimate 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 healing potential 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 (free movement >6 months).
Classified as hypervascular (hypertrophic) or avascular (atrophic) based on their biologic reaction. Treatment includes injection of bone marrow or other osteo-stimulating materials, more secure internal fixation, excise gap tissue, apply compression across gap, bone graft, electrical stimulation, and prosthetic replacement. Malunion (heal in a 'crooked' position) May result from management problem or unavoidable. Causes shortening where overlap. Treatment means correction-ostetomy .NB shortening can also result from bone loss or growth plate injuries. Avascular necrosis (AVN) Bone death. Seen in intra-articular fractures especially of the femoral head/neck/ femoral condyles/ proximal scaphoid/ talar neck and proximal humerus. From disruption of the blood supply. AVN causes nonunion, may lead to OA and collapse Infection Possible complication of open fractures (immediate and adequate debridement of all open fractures is essential - both initially, and again if infection becomes apparent). Watch for ‘fight bites’ and the bites of cats or dogs. Symptoms are persistent pain, stiffness and progressive, concentric joint space narrowing. May result in severe pain, systemic disturbance or become life threatening. Beware of tetanus caused by clostridium tetani which flourishes in dead tissue (an exotoxin which passes to the CNS). Avoided by early toxoid boosters and extreme care. Signs and symptoms are contractions (jaw asphyxia). Treatment includes→and facial muscles then diaphragm, intercostals IV antitoxin /heavy sedation with a muscle relaxant/ tracheal intubation, if necessary. Gas gangrene Due to clostridium species or, in rare cases, a G. streptococcal infection. Severe symptoms within 24 hours include a foul smelling, serosanguinous brown discharge, oedema, progressive pain, ultimate toxaemia and coma. A life threatening condition. Treatment includes penicillin G, 20 million units per day in adults, and clindamycin, hyperbaric oxygen, and amputation if advanced. Toxic shock syndrome Caused by gram-positive bacteria superinfection results from toxaemia not septicemia. Symptoms (severe) are fever, hypotension, an erythematous macular rash, systemic disturbance and serious exudate (Gram +ve cocci). Treatment requires I & D ASAP plus IV antibiotics/+IV fluid. Necrotizing fasciitis An aggressive, life threatening fascial infection usually with an underlying vascular disease (e.g. diabetes). Often associated with streptococcal gangrene and polymicrobial with both aerobes and anaerobes). Treatment is: wide surgical I &D/IV antibiotics
Acute osteomyelitis May develop into chronic osteomyelitis. Occurs in metaphyses or epiphyses of long bones. Staph. aureus is the most common organism. Symptoms include pain/loss of function, +/- soft tissue abscess with soft tissue swelling, demineralization, +/- sequestra/in the latter stages- involucrum. Treatment is to identify organism, select and give appropriate antibiotics, halt tissue destruction. Soft tissue (direct/indirect injuries to nerves/ vessels/soft tissue) Key points • Determines final function.
arterial: rare but devastating. Seen with shoulder dislocations, knee dislocations, and supracondylar elbow fractures. Repair, if necessary, within 6 hours. Fasciotomy may be required. See Chapter 00. Nerve injuries, uncommon, most injuries are neuropraxias from stretch (>70% heal within 6 weeks). See pages 00
Compartment syndrome: garments.
pressure can lead to serious sequelae. Further
risk with use of antishock
Key points • Compartment syndrome is most common following serious injury to the forearm and/or leg.
Symptoms include pain (
with active and passive movement of muscle involved), paraesthesia, and much later (too
late)-pallor, paralysis, pulselessness See Chapter 00. Treatment includes fasciotomy within 48 hours (to avoid muscle necrosis) and judicious muscle debridement for any ischaemic muscle lacking the capacity to bleed or contract.
Pulmonary complications • Pulmonary embolism; the most common pulmonary complication. Requires: intermittent pneumatic compression, low-molecular-weight heparin and warfarin.
Adult Respiratory Distress Syndrome (A.R.D.S.): from aspiration/inhalation or from shock/sepsis. Hallmark is pulmonary oedema/ pulmonary function, made worse by prolonged hypovolaemia and left ventricular
function. A.B.G is useful. Treatment is with ventilation with P.E.E.P.
Fat embolism: a a form of A.R.D.S. which usually follows cases of multiple fractures, mostly the long bones. Results in changes in chylomicron stability and conversion to free fatty acids in the lung tissue. Symptoms, within 72 hours, are:tachycardia, hyperthermia, tachypnoea, hypoxea and change in mental state (confusion). Treatment includes: stabilization of the bony injury (the earlier the better, especially for pelvic fractures) and pulmonary support (steroids may help).
Bleeding disorders Excessive bleeding can cause hypovolemic shock and disseminated intravascular coagulation (shock= the manifestation of tissue perfusion). It causes: pale & cool extremities/oliguria/tachycardia antithrombin III, fibrinogen and values of PT/PTT and fibrin split
Diagnoses of D.I.C. is made by noting products.
Treatment includes: immediate whole blood, I.V. fluids, dextran solutions, treat underlying cause, cautious use of heparin, platelets and DDAVP as excessive anticoagulation can lead to bleeding into the soft tissues. Avoid albumin. Incresed swea G.I. complications (either the result of trauma or a complication). Include stress ulcers, cast syndrome(from compression of the 2nd part of the duodenum by the superior mesenteric artery, with small bowel obstruction and projectile vomiting; seen with spine fractures in POP). Treatment: remove cast and place nasogastric tube. Reflex sympathetic dystrophy (also known as complex regional pain syndrome type 1) . This is a neurological disorder after trauma, surgery or immobilization. There is intense pain, a vasomotor disturbance, increased sweating, slow recovery, dryness, swelling, osteopaenia, and skin changes. Said to be caused by a sustained efferent sympathetic activity locked into a reflex loop. Used to be called causalgia. Lankford and Evans have described 3 stages:
Acute. Onset within 3 months, there is pain, swelling, redness, Three-phase bone scan is positive.
ROM, and sweating. X-ray is normal.
Subacute. Onset 3 to 12 months. Chronic. > 12 months.
pain, blueness, dryness,
stiffness, skin atrophy, osteopaenia
pain, fibrosis, dry and cool skin, stiff joints, extreme osteopaenia.
Diagnosis is made on 4 main signs (large amount of pain, swelling, stiffness, discolouration). Use thermography, xrays, and bone scan.
Treatment. Make early diagnosis. Use Physeiotherapy (ROM, fluidrotherapy and TENS). Sympathetic nerve blockschemical (four of the stellate ganglion) or if unsuccessful then surgical (after > 6 months). Also add- N.S.A.I.Ds and psychological help. Late complications • • • • Myosotis ossificans. Occurs where large haematomas, as late as 6months post injury. Post traumatic OA Commonly follows intra-articular fractures (if not anatomically reduced). Treatment is adult reconstruction. Immobilization hypercalcemia. Rare. Seen after children and in Paget’s disease. Symptoms are nausea, vomiting, severe abdominal pain and acute personality changes • Heterotopic ossification. Seen after acetabular fracture surgery and in head injuries. Treatment is with indomethacin and irradiation
Key points The essential long-term goal of all orthopaedic trauma care is to avoid/minimize the development of secondary OA. Soft tissue trauma Important. May be severe or life threatening. Occurs with initial bone trauma then subsequently care.
Thermal burns: freezing injuries, burns, electrical shocks, burns, chemical burns, chemotherapeutic extravasation. See also chapter 00. Treatment is symptomatic, avoid infection, and sometimes amputation (with electrical injury).
High pressure injection injuries. From accidental injections (paint or grease guns) with resultant tissue necrosis or fibrosis. Treatment is IV antibiotics, I&D plus steroids.
May produce extensive soft tissue destruction often leading to compartment syndrome. See chapter 00. Principles of ORIF (Open Reduction and Internal Fixation) Not all surgical details included here; only for common operations and as needed for inexperienced clinicians/surgeon; some cases e.g. anterior acetabular fractures should probably only be done by an experienced pelvic surgeon who would not need this book. The AO school has worked out the principles of ORIF. "The Manual of Internal Fixation" is essential reading . Key points
Fractures which are almost always treated by ORIF: pathological (especially tumours); femoral in adults and femoral neck in children; polytrauma and where nursing diffculties (elderly and multiple injuries).
Fractures almost never treated ORIF: most children's fractures; tibial shaft non-displaced; those of the unreliable and the disturbed (interpret as you will).
The following fixation devices are commonly used. Pre-operative planning is essential as well as a thorough knowledge of the local anatomy, mechanical demands and injury characteristics. See Appendix 00 for surgical approaches, p. 00 Fixation devices (Fig 13.3)
• • •
plates/screws: Lag screws are often used with compression plates (basis for AO technique). Compression of the fracture is achieved by overdrilling the proximal cortex. compression plate(DCP):used on the tension side of transverse or short oblique fractures. They provide stability and act as "a load sharing device" . reconstructive plates: useful for pelvic and distal humerus fractures. They are pliable and allow positioning for use as a neutralization plate. intramedullary fixation (IM nails);old technique but still commonly used and successful method of fixation for lower limb diaphyseal fractures .Allow early WB/place with a closed technique/allow good axial alignment but canal diameter can limit size of nail used/disrupts endosteal blood supply/may cause embolism/may need to lock to achieve rotational control/remove after 12 months.
IM pins: reaming not required; may also be used in children (e.g. Nancy Nail from Landos). external fixation: useful for Grade 111 open tibial fractures. Where access to wound. Also for ant disruption pelivis/distal radial fractures. risk of infection for ORIF/allows
special devices: many, most useful are dynamic hip screws, a load sharing device allowing screw insertion at various angles, most useful for femoral neck fractures; cannulated screws, very useful, for a variety of fractures, especially femoral neck fractures, use guide wires; DC screw sideplates, useful for unstable subtrochanteric fractures and distal femur fractures; tension band wiring, allows fixation on the tension side and so relies on motion to promote union on the compression side, parallel K-wires placed close to the outer cortex with cerclage wire under these before being tightened to apply compression, use for patella and olecranon fractures.
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