General Principles of Fracture Management SWOTA 2010

Thomas A. DeCoster, M.D. Chief, Division of Trauma Vice Chair, Orthopedics University of New Mexico President, SWOTA

Which is the clearest description of a forearm fracture?

A. Radius and ulna shaft fracture. B. BBFA C. Fracture of necessity D. Piedmont fracture E. Broken Arm

OUTLINE
1 Fracture Definition 2 Classification
OTA

3 Healing response 4 Common treatments 5 Complications

Fracture Definition
A broken bone

Your fracture pt evaluation

ER Respond quickly and nicely Talk to the patient EXAMINE the patient Review radiograph Call/notify superior Document (pre-op, f/u, etc.)

Fracture evaluation Clinic

Review current and prior radiographs Review prior notes Examine the patient Identify normal and abnormal healing Formulate a plan
Type and length of immobilization Return to work Analgesia Follow-up

Diagnosis
Physical Exam
Palpate the bones Crepitus Related
Skin Neurovascular exam

X-ray
Linear radiolucency through bone Indirect signs

Whats the diagnosis in this case?

Correct answer
Right femur shaft (R32)fracture
Even better
Wedge Comminution (32-A) Transverse (32-A3) Middle 1/3 (32-A3.3)

Right patella fracture (R34)

Insufficient information for further designation

Incorrect
broken leg subtroch femur fracture (not specific enough-need Right femur shaft to be correct)

Fracture Classification

Name the bone!!!

Sounds easy, but its not Then the bone part (proximal, shaft, distal) for sufficient specificity

Fracture Classification General Principles

Group similar injuries Separate dissimilar injuries IMPROVE communication Identify prognosis and complication risk DIRECT TREATMENT Enhance research

Qualities of a good classification system

All inclusive Mutually exclusive Reliable Reproducible Clinically relevant Logical
Oxford Textbook of Orthopaedics 2002 DeCoster

Eponyms
Formerly prevalent Fortunately passing into disrepute Unfortunately persist as jargon/code You need to be aware of them but you do not need to use them Distal radius fracture NOT Colles fx

Fracture Classification
Name the bone Proximal, Shaft or Distal
Use rule of squares Know the exceptions

OTA/AO 2007 JOT November Examples

Fracture classification example

Right femur shaft (R32) p S35 Not distal femur (rule of squares) Not proximal femur (distal to lesser troch) Wedge comminution R32-B Wedge=butterfly Not simple (A) Not complex=segmental comminution (C)

Example 32-B
Transverse (32-B3)
Not spiral (B1) Not oblique more than 30 degrees (B2) Less than 30 degrees is transverse (B3)

Middle zone (32-B3.2) p S37

Not subtrochanteric zone (.1) Not distal zone (.3) Middle 1/3 OF THE SHAFT (.2)

More examples
Saturday evening Other talks

How do fractures heal? (one word)

Fracture healing in a word

CALLUS

Callus
Fracture healing occurs as mesenchymal cells differentiate and produce progressively stiffer matrix. Phases
Hematoma Inflammation Callus
Soft Hard

Re-modelling

Timing of Callus formation in humans

Hematoma Inflammation Soft Callus Hard Callus Re-modelling 2 hrs 2 days 2 weeks 2 months 2 years

Healing strength
Hematoma Inflammation Soft callus Hard callus Re-modelling 1% 5% 25% 75% 110%

Fracture healing is spontaneous and natural and does not require surgical intervention
You do not NEED to operate on a fracture to make it heal Most interventions interfere with healing more than they help But there are many advantages to operative treatment of fractures-but making the fracture heal is not generally one of them

Impact of treatment on healing

Reduce displacement and improve alignment so that when it heals there is good function Stabilization of the fracture allows mobilization of the patient But also many negative impacts

Fracture treatment
Immobilize the fracture Mobilize the patient Avoid fracture disease Avoid complications Allow healing

Fracture Initial Treatment

Splint Analgesia Elevation Follow-up

Fracture Treatment OPTIONS

Closed
Non-operative Splint Cast Traction

Fracture Treatment Options

Operative
Closed reduction Percutaneous pinning External fixation Internal fixation Prosthetic replacement

Internal Fixation
Open reduction internal fixation ORIF
Classic plate and screws Screws alone (rare) Locked plating (recent)

Internal Fixation-Types
Intramedullary nailing
Reamed vs. unreamed Rigid vs. flexible Closed vs. Open Locked vs. unlocked Statically locked vs. dynamic

Initial Post-op Care-PGY2 issues

Incision Swelling Pain Elevation Patient mobilization

Rehabilitation
Mobilization of the body part Mobilization of the patient Progressive weight bearing
Fixation type Healing time

Open Fractures
Skin is broken Infection the big problem
Closed fx infection rate = 0% Open fx infection rate = 20%

Osteomyelitis is forever

Fractures Local Complications

Nonunion Failure to heal 3% overall 50% of some particular fractures Related to treatment, local problems, systemic problems (e.g. Smoking)

Nonunion Treatment
Stabilization
Hypertrophic Nonunions New fixation

Stimulation
Atrophic nonunions Bone graft Other (Estim, ultrasound, BMP)

Malunion
Healing in poor position
Crooked = deformity Displaced - risk of arthritis

Malunion Treatment
Prevention Straightening Salvage

Fracture Systemic Complications

Fat embolism syndrome
Marrow elements (fat) released into the vascular system and travel to the lungs Triglycerides (fat) metabolized to FFA by pneumatocytes and these FFS are toxic to tissue Especially brain, blood vessels, kidney ARDS Risk of death

Diagnosis of Fat Embolism

ARDS
Mental status changes Petechiae Other

Treatment of Fat Embolism

Respiratory Support Early recognition

Systemic complication DVT/Pulmonary embolism

Fracture leads to immobilization Stasis, hypercoagulability, intimal injury Thrombosis of LE veins Embolism to heart and then lungs Mechanical blockage Ventilation/perfusion mismatch

DVT/PE
Respiratory depression Cardiac Death

DVT Prevention
Mobilization
Patient Limb

Mechanical
Skeletal stabilization SCD, foot pumps Compression

Chemical anticoagulation

Fractures Summary
1. Classification
OTA 2007 Name the bone Proximal/Shaft/Distal

2. Healing Callus 3. Treatment options 4. Complications

SWOTA : 2010

Resident Course - Fundamentals of Fracture Care

CLOSED TREATMENT OF FRACTURES

Helpfulness of Material

A) Worst

B) Bad

C) OK

D) Good

E) Best

COMMENTS Please

SWOTA : 2010
Resident Course - Fundamentals of Fracture Care

CLOSED TREATMENT OF FRACTURES

Quality of Presentation

A) Worst

B) Bad

C) OK

D) Good

E) Best

COMMENTS Please