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Orthopaedic Trauma อ.ธีรชัย
Orthopaedic Trauma อ.ธีรชัย
21
35
46
58
6 Spinal Injuries
79
98
8 Open Fractures
110
120
10 Complications of fracture
134
Fracture Principles
1 Fracture Principles
__________________________________________________________________________________________
Terminology of Fractures
Anatomic location
proximal, middle distal thirds
epiphysis, metaphysis, diaphysis
Direction of fracture lines ( 1.1 )
Transverse :
Oblique :
30-60
Spiral :
Comminuted :
2
(segment) (butterfly
fracture)
Impacted :
2
(osteoporosis) cortex
metaphysis proximal humerus
Fracture Principles
transverse oblique fracture
spiral comminuted fracture
1.2
( Eponym)
2
Fracture Principles
( 1.3)
Nightstick fracture : ulnar
Chauffeurs fracture : radial styloid
radial styloid
Boxers fracture :
metacarpal neck 4 5
March fracture :
metatarsal neck 2 3
!"#$%&%"'()*+,'%-+.
!"#$%&'()%*+,-%$
1.3
Joint Injuries
Sprain : 3
First degree :
Second degree :
Third degree :
Subluxation :
partial dislocation
Dislocation :
luxation
Fracture Principles
Fracture Healing
Fracture Principles
union callus
3.( Remodeling phase ( 1.7)
Wolff law stress
stress
Fracture Principles
1.(
- , , ,
- open
fracture 8 contamination
wound infected wound
- open fracture
-
open fracture
2.(
3
1.! life threatening condition, resuscitation
2.! (screening test)
3.!
Fracture Principles
Screening test
(compression test)
sternum 2
anterior superior iliac spine 2 2
pubic symphysis
(log rolling)
Fracture Principles
3.
1.!
2.! 2 anteroposterior lateral
3.!
4.! ossification center accessory
ossicle 2
5.!
6.!
C-spine open mouth
1 (atlas) 2
(axis, odontoid)
C-spine swimmer s view lower cervical spine, upper thoracic
Transcapular view
head humerus scapular
Lateral
Scaphoid view (PA) fracture scaphoid
Pelvis inlet, outlet
Judets acetabulum
Hip lateral cross table lateral proximal
femur
skyline view
vertical fracture patella
osteochondral fracture
Fracture Principles
ankle mortise
distal
tibiofibular joint
calcaneus
calcaneal axial
!
5
(5R)
1.( Recognition
2.( Reduction
3.( Retention
4.( Rehabilitation
5.( Reconstruction
5R 6R Refer
(Reduction)
(Retention)
Reduction
(displaced)
(non-displaced)
impacted fracture
displaced fracture
9
Fracture Principles
2
1. Closed reduction
1.1! (closed manipulation)
Retention
Colles fracture
scaphoid
fracture
1.( (Casting)
closed manipulation
retention
2
Comminuted fracture of tibia
10
Fracture Principles
3.( (Internal fixation osteosynthesis)
plate and screw, intramedullary nail, wire
4.( (External fixation)
pin schanz screw
open fracture closed fracture
hematoma, inflammation
pain reflex immobilization
fracture disease (LucasChampioniere 1907)
Pathogenesis of fracture disease pain,reflex immobilization bone muscle
complex physiologic load edema, intermuscular fibrosis muscle
atrophy chronic edema, soft tissue atrophy
patchy osteoporosis (disuse osteoporosis) physiologic load
11
Fracture Principles
fracture disease
active pain-free mobilization physiologic load bone muscle complex
joint stiffness muscle atrophy
early exercise
(intramedullary nail) (plate and screw)
(external fixation) open reduction internal fixation (ORIF)
early exercise ORIF external
immobilization
internal fixation
(bone healing mechanism)
internal fixation
(implant failure)
internal fixation
1.! anatomical reduction articular surface
post traumatic arthritis diaphysis
rotation
periosteum
(sequestrum)
2.! Stable internal fixation internal fixation
early exercise fracture disease
3.! Preservation of blood supply incision
handle soft tissue atraumatic surgical technique
bone healing
4.! Early active pain free mobilization bone muscle complex
physiologic load joint stiffness osteoporosis
12
Fracture Principles
13
Fracture Principles
Timing of Operative Treatment
factor
, associated injuries chest, abdominal trauma
Surgical procedures 3
1.( Emergency open fractures,
irreducible dislocation of major joint, unstable spinal injuries, unstable pelvic
14
Fracture Principles
15
Fracture Principles
External Fixation
wire, pin schanze screw
External Fixator
1.! open fracture open fracture type II,III
burn flap skin graft
2.! (limb lengthening)
3.! (arthrodesis)
4.! (infected fracture or nonunions)
5.!
6.!
7.! internal fixation
External Fixator
1.!
2.!
3.!
4.! (skin and bone graft)
5.! external fixator
6.!
External Fixator
1.! pin tract infection
2.! ring fixator
3.!
4.! pin
16
Fracture Principles
fracture healing
! (clinical union)
-( callus 2
callus
!
-( clinical union 6-8
3-4
! U-slab fracture humerus long arm cast fracture
forearm 6 clinical union long leg
cast fracture tibia clinical union PTB cast
17
Fracture Principles
-( humerus. forearm
tibia
weight bearing bone
PTB cast 8-12
intraarticular fracture fracture neck of femur
-( synovial fluid enzyme fibrinolysin blood clot
callus formation
1.! (osteosclerosis)
2.! (obliterate canal)
3.!
4.!
-(
(non-displaced fracture)
18
Fracture Principles
!
-(
bone graft
!
-( stainless steel
Titanium inert metal
!
-( upper extremity implant
acetabulum implant
lower extremity weight bearing bone
bone remodeling 18-24
19
Fracture Principles
20
B.! 2
C.!
D.! neurogenic shock
venous return
21
! Splint ( 2.3)
A.! Pillow splint distal leg, ankle
! casting
(CaSo4 )2 H2O + 3 H2O = 2 (CaSo4 . 2 H2O) + heat
2
1.!
2.! fiber glass
22
1.! slow, fast
extra fast setting
2.!
3.!
4.!
(webril) (stockinette)
(cast spreader)
Basic principle
A.!
1.! (immobilize)
2.! (early ambulation)
3.! (correct deformity)
4.! (prevent deformity)
B.!
soft tissue periosteum
three-point fixation
curved cast provide straight alignment ( 2.4)
2.4 three
point fixation
23
!
soft tissue splint
!
short arm cast Colles fracture
pronation ulna deviation 3-point fixation
PTB cast femoral condyle proximal
tibia
C.!
1.!
2.!
4
6 6 3 webril
3 4 6
3.! (circular cast)
compartment syndrome slab
4.!
5.! (stockinette)
webril
webril webril
( 2.7)
24
2
webril 3-4
2.7 webril
6.!
( 2.8)
( 2.9)
2.8
2.9
7.!
4-6 mold
stockinette webril
webril
25
9.!
10.!
24-36
! splint (slab)
posterior splint
slab
slab
slab 8-10 4 slab
10-14 4 6
2.10 slab
2.11 slab
26
webril slab
1.!
2.!
3.!
4.! 2-3
5.!
6.!
7.!
.!
.!
.!
.!
.!
8.!
(cast windowing)
window
window
bandage
window
(window edema)
27
2.12
D.!
compartment syndrome
1.!
2.!
(vibration)
1.!
2.!
2
(bivalve) ( 2.13 )
3.!
4.!
( 2.14 )
5.! webril stockinette
6.!
elastic bandage
exercise
28
2.13 2 (bivalve)
2.14
E.!
1.! U-slab sugar tong ( 2.15)
fracture shaft of humerus slab
6-8 distal end clavicle
1
2.15 U-slab sugar tong
internal rotation support
forearm arm sling
2.! Long arm cast ( 2.16) supracondylar
fracture humerus, fracture forearm
deltoid
distal palmar crease head
metacarpal 90
2.16 Long arm cast
3.! Short arm cast fracture distal radius
Colles fracture
long arm cast
30
! Traction
traction
1.! maintain length alignment stability
2.! traction proximal tibia
traction Pearson attachment Thomas splint (Balanced traction)
3.! (muscle spasm)
Buck s traction hip injury
4.! traction
Skin traction
definite treatment
10 4
4-6
2.!
fibular neck
3.! elastic bandage
elastic bandage
Skeletal traction
Kirschner wire (K-wire) Steinmann pin
wire pin 2 (smooth) (threaded)
31
osteoporosis
pin wire
1.!
2.!
3.!
pin vital structure
olecranon pin medial lateral ulnar nerve
4.! infection
5.! subcutaneous
periosteum
pin
6.! pin
K-wire pin
pin
skin necrosis, pin tract infection
7.! pin metaphysis
cortical bone epiphyseal plate
tibial tubercle distal femoral epiphysis
8.! pin open fracture
9.! pin distal femur
Skeletal traction
1.! Metacarpals K-wire diaphysis 2nd 3rd metacarpal 1st
interosseous volar K-wire dorsal
2.! Olecranon distal olecranon process 1
90 medial lateral ulnar nerve
3.! Distal femur just proximal adductor tubercle
upper pole patella mid coronal distal femur
medial lateral popliteal vessel
32
34
deformity
35
36
AC
dislocation
Type I
Type II
Type III
AC ligament CC ligament
Sprain
Tear
Intact
Sprain
Tear
Tear
Deformity
No
Slight AC
prominent
Gross AC
prominent
Treatment
Sling 7-10 day
Sling 1-2 weeks
ORIF
37
displaced
1.! displaced 1 .
2.! Angulation 45
2, 3 4
displaced displaced
2 parts, 3 parts 4 parts fractures
ORIF plate,
3.6 Displaced fracture of
screw
proximal humerus
39
conservative 6-8
1.! Coaptation splint (Sugar tong, U-slab)
distraction splint 2 shaft ( U-slab)
4-6 2-3
functional brace
2.! Hanging cast 1
45
1.! vascular injury
2.! multiple injury
3.! open fracture
4.! bilateral humeral fracture
5.! pathological fracture
6.! radial nerve palsy closed reduction
7.!
8.! non union
41
! Fracture Olecranon
2 direct injury comminuted fracture
triceps transverse fracture
Non displaced fracture 3
1.! 2 .
2.! 90
3.! gravity
posterior long arm slab 2-3
Displaced fracture K-wire plate screw
! Elbow Dislocation
90% posterior posterolateral
olecranon process
Heuters line medial
epicondyle,olcrenon,lateral epicondyle fracture radial
head, coronoid process, medial epicondyle dislocation radial artery
median, radial, ulnar nerve ulnar
nerve
2. Parvin ( 3.10)
3-5 2-3 distal humerus
42
reduction
! mechanical block
! 15-20
1 active
exercise
anatomical reduction
1.! Non displaced fracture
long arm cast 4-6
2.! Displaced fracture ( 3.11) ORIF plate screw
exercise
3.11 radius
ulnar ** **
43
! Monteggia fracture
Fracture proximal 1/3 ulnar radial head dislocation ( 3.12)
fracture ulnar radial head
fracture proximal ulnar radial head AP
lateral elbow radial head capitullum 2
capitullum radial head dislocation
44
! Nightstick fracture
Isolate fracture ulnar shaft direct injury
45
Colles fractures
Abraham Colles ..1814
distal radius 2.5 ..
distal fragment dorsal radial (
4 . 1 )
osteoporosis
4.1 Dinner fork deformity
displaced fracture
Colles fracture
dinner-fork deformity nondisplaced minimally
displaced fracture deformity distal radius
median nerve proximal fragment
Anesthesia
1.! General anesthesia
2.! Regional anesthesia
3.! Local hematoma anesthesia ( 4.2)
simple
fracture
(reduction)
* pronation *
( 4.3)
Chinese finger trap
(degloving skin)
-! 1 Disimpaction
hyperextension soft tissue hinge ( 4.4)
-! 2 Traction distal fragment
extension dorsal cortex
volar flexion ( 4.5)
-! 3 Volar flexion dorsal cortex distal fragment
volar ulnar deviation ( 4.6)
volar flexion
15-20 , ulnar deviation pronation
3
47
4.3 Diagram
Colles fracture
4.4 Disimpaction hyperextension
reduction fluoroscopy
closed reduction
osteoporosis volar tilt 0-10
48
radial height 5 .
arm sling
arm sling
arm sling
arm sling *
*
(Follow up)
1-2
24-48
1.!
2.!
3.! slab
(fluoroscopy) 10-14
49
?
non displaced fracture 1-2
6
displaced fracture 2-3
1-2
6
(clinical union)
Colles fracture
re-manipulation osteoporosis
malunion
malunion
Colles
fracture traction supination
distal fragment volar dorsal
50
Bartons fracture
fracture dislocation subluxation rim distal radius
dorsal rim Dorsal Bartons fracture ( 4.9) volar rim Volar Bartons
fracture ( 4.10) intraarticular fracture anatomical
reduction
plate screw K-wire
51
! Scaphoid fracture
carpal bone
dorsiflex
90 scaphoid
distal ( 4.12) proximal
avascular necrosis proximal
fragment chronic wrist pain
snuffbox dorsal 4.12 Vascular supply
scaphoid tubercle volar
scaphoid distal
PA ulnar deviation
scaphoid
! Hand fracture
splint
safe position ( 4.13)
MCP joint 90
52
Mallet finger
4.14
distal
phalange
53
4.17 rotation
4.18 rotation
scaphoid tubercle
54
malrotation 5 shortening 5 .
angulation 20 closed reduction AP slab MP joint 90
PIP 10-15 DIP 0-10
comminuted fracture multiple fracture
K-wire, plate, screw
Bennetts fracture
intraarticular fracture dislocation
carpometacarpal joint (CMC)
stable adductor pollicis
abductor pollicis longus (APL) fracture
displacement ( 4.20)
fracture dislocation
closed reduction
fluoroscopy percutaneous K-wire fixation
thumb spica 6
55
MP Joint dislocation
dorsal dislocation 2
simple complex simple dislocation
MP joint hyperextension 60-80
complex dislocation MP extension 20
( 4.22)
56
57
pelvis
fracture sarcrum, ilium
fracture pubic rami
58
pelvis AP lateral
compression test pubic symphysis pelvis
AP, inlet, outlet view
1-2
4-6
2.! Unstable injury AP compression injury pubic symphysis
2.5 . vertical shearing 2
2.1!Vital sign stable
-! AP compression injury pelvic sling pelvis
ORIF pubic symphysis
-! Vertical shearing distal femoral traction definite
treatment ORIF
2.2!Vital sign unstable
(20-40%)
resuscitation, blood transfusion
59
! Fracture Acetabulum
(dashboard injury)
greater trochanter
(post traumatic
arthritis) (recurrent dislocation)
pelvis AP Judet s view (internal, external oblique)
! Hip dislocation
avascular necrosis
pathognomonic sign
flexion, abduction external rotation hip
joint femoral vessel nerve
dorsalis pedis posterior tibial
artery sensation femoral nerve
motor
quadriceps femoral
head acetabulum obturator
foramen( 5.4)
closed reduction
general anesthesia Alliss
maneuver( 5.5)
pelvis
adduction internal rotation
lateral traction
skin traction 1
2-4
61
Posterior Dislocation
80% ( 5.6)
(simple dislocation) (fracture-dislocation)
flexion, adduction
internal rotation posterior
dislocation sciatic nerve
( 5.7)
sensation common peroneal nerve
tibial nerve motor
common peroneal nerve
dorsiflexion tibial nerve 5. 6 Posterior dislocation of
the hip
plantar flexion
62
5
.
proximal femur
1.! Shentons line ( 5.9)
superior pubic rami
medial neck shaft femur
63
64
! Intertrochanteric fracture
extracapsular fracture greater lesser trochanter
greater trochanter (ecchymosis)
external rotation fracture neck of femur
conservative treatment
traction 6
venous thrombosis, pressure sore, pneumonia, UTI
internal fixation( 5.11)
5.11 Intertrochanteric
fracture
! Subtrochanteric fracture
lesser trochanter 5 .
lesser trochanter 2
1.! high energy trauma
65
A. extra articular
B. partial articular
C. complete articular
! articular fracture
! (knee axis)
1.! Non displaced fracture impacted fracture
osteoporosis long leg cast 2-3 knee
brace
66
5.12
A type -Extra-articular fracture
B type -Partial-articular fracture
C type -Complete-articular fracture
! Knee dislocation
orthopaedic emergency injury
popliteal artery common peroneal nerve
tibia
anteior
dislocation ( 5.14) dorsalis pedis, posterior tibial artery common
peroneal tibial nerve reduction
closed
reduction traction tibia
distal femur
pulse angiography
,vascular repair
late
thrombosis popliteal artery 1
ligament injury
"#$%&'(&
)(*$%&'(&
+"$%&"+
! Knee injury
knee injury
1.! dashboard injury PCL injury
(valgus) MCL injury
2.! ACL injury, meniscus injury patella
subluxation
68
3.! swelling
! Immediate hemathrosis rupture ACL, PCL meniscus
tear, intraarticular fracture, tear joint capsule
! Late effusion inflammation
4.! Instability
! Giving way ACL
laxity
5.! Locking
meniscus tear, loose body, ACL tear
6.! Pain, tenderness
! Joint line tenderness meniscus tear
! medial adductor tubercle proximal tibia MCL
injury
! lateral lateral epicondyle fibular head LCL injury
! Medial retinaculum patella dislocation
Meniscus injuries
Meniscus
! (click)
! meniscus
! joint line
! McMurrey test, Apley test positive
(arthroscopy)
partial menisectomy
meniscus repair arthroscopy
69
ACL injury
! Associate ligament injury
!
!
!
3
1.! Conservative 3-4 knee brace
activity associate injury
2.! Surgical repair 50%
3.! Reconstruction
ACL
semitendinosus, bone patella tendon bone graft
! Tibial fractures
tibia
open fracture infection
tibia
1.! initial displacement 50%
90%
2.! comminution
3.! soft tissue injury open fracture compartment
syndrome
4.! infection
72
! Ankle Sprains
sport injury 85% lateral ligament injury
(inversion) plantarflexion anterior talofibular
ligament
lateral malleolus
anterior drawer test distal tibia
talus talus
Grade I, II
exercise
grade I,II
73
! Ankle Fracture
talus ankle mortise injury
Denis-Weber fibular syndesmosis (
5.15)
Type A
syndesmosis
Type B syndesmosis
Type C syndesmosis talus unstable ankle
posterior tibial dorsalis pedis artery
bony structure
ligament
ankle AP, lateral
mortise view
5.15 Denis-Weber classification
! Talus Fracture
talus 60% cartilage
talus talar neck
hyperdorsiflexion talus neck anterior lip tibia
body talus
74
! Calcaneal Fracture
Calcaneus tarsal bone
talus posterior articular facet calcaneus
calcaneus ( 5.17) Bohlers tuber angle posterior
facet 25-40
76
77
Avulsion fracture
compression dressing 2-3
6-8
Jones fracture acute fracture short leg cast 6
non-union curettage bone graft
78
Spinal Injuries
6 Spinal Injuries
---------------------------------------------------------------------------------------------------------------------------------------
79
Spinal Injuries
1.!
2.!
3.! spine
80
Spinal Injuries
Spinal Injuries
SCI
Location
Functional impairment
Prognosis
Brown-Sequard
Hemicord
Ipsi. Motor weakness
Good
syndrome
Contra. Loss of pain, temp
Anterior cord
Anterior 2/3 Motor loss, loss of pain temp
Poor
syndrome
below injury level
Posterior cord
Posterior
Loss propioceptive, vibratory
Fair
syndrome
column
spare sensory, motor function
Central cord
Central area Motor weakness arm, hand >
Fair
syndrome
leg, sensation spare
1.! sensation dermatome
2.! muscle power nerve root
3.! reflex upper lower extremity
4.! sacral sparing perineal sensation, toe flexor sphinctor tone
82
Spinal Injuries
Sensory evaluation
pain,temperature
spinothalamic tract anterolateral
spinal cord position sense
posterior column C1 occipital
area C34 S234
dermatome ( 6.4)
sensation perineum
sacral sparing ( 6.5)
Motor evaluation
nerve
root C5 deltoid S1 toe
flexor ( 6.6) motor sacral
sparing voluntary sphinctor
contraction great toe flexor ( 6.5)
sacral sparing
spinal injury
sacral sparing functional
6.5 sacral sparing
recovery sacral sparing
sacral cord perianal
spinal cord
sensation great toe flexor
sacral sparing
spinal shock motor sensation
injury
complete cord lesion motor sensation
spinal cord injury
83
Spinal Injuries
84
Spinal Injuries
Open - mouth
Lateral
Demonstration
! Fracture of the bodies of C3-C7
! Fracture of the lamina of C3-C7
! Abnormal rotation of spinous process
! Uncovertebral (Luschka) joint
! Fracture of lateral mass of C1
! Fracture of odontoid process, body of C2
! Jeffersons fracture
! Atlantoaxial rotatory subluxation
! Fracture of anterior, posterior arch C1
!
!
!
!
!
!
!
Oblique
Swimmers
! Intervertebral foramina
! Apophyseal joint
! Fracture, dislocation of C7, T1, T2
85
Spinal Injuries
86
Spinal Injuries
3.! structure
3.1! prevetebral soft tissue shadow hematoma
C1 8-10 .
C3,4 3 . 5 . indirect evidence CSpine injury C4-7 10-15
3.2! vertebral body (anterior vertebral line)
compression fracture body, avulsion
fracture superior inferior rim body anterior
translation < 25% body unilateral facet locked
anterior translation > 50% body bilateral facet locked
3.3! vertebral body compression fracture burst fracture
bony spur cervical spondylosis
3.4! Disc space narrowing disc degeneration acute
cervical disc herniation
3.5! body (posterior vertebral line)
spinal canal (retropulsed
fragment)
3.6! Spinal canal funnel shape posterior vertebral line
spinolaminar line ( 6.8)
3.7! Facet joint inferior facet vertebra articulate
superior facet vertebra facet dislocation
inferior facet vertebra superior ferior
facet vertebra
3.8! Spinous process widening
interspinous ligament fracture spinous
process
4.! lateral view C1-C2
4.1! anterior arch odontoid process (ADI) ADI
atlantoaxial rotatory subluxation
rupture transverse ligament
87
Spinal Injuries
88
Spinal Injuries
! Odontoid Fracture
spinal injury miss diagnosis
lateral view soft tissue abnormal curvature
odontoid process body C2 AP
open mouth
Anderson D Alonzo odontoid fracture 3 ( 6.12)
Type I apex of dens avulsion fracture
alar ligament type stable injury cervical collar 4-6
89
Spinal Injuries
Type II
base dens body
non union 10-67% 2
skull traction 6
SOMI brace 6 film
lateral flexion, extension
C1-C2
Type III body
C2 cancellous bone contact
surface
skull traction 4 SOMI
12
extension
axial load
AP, open mouth
lateral view
body
6.13 Non-displaced fracture displaced fracture
pedicle C2
type
4 type non-displaced displaced ( 6.13)
1.! Non-displaced fracture 3 .
C2 C3 stable fracture SOMI brace
2.! Displaced fracture 3 . C2 C3
reduction skull traction
6 SOMI brace 6
reduction fusion C1 C3
90
Spinal Injuries
Facet Dislocation
-! Unilateral facet dislocation facet 1
(torticollis) body
25% body nerve root compression 1
-! Bilateral facet dislocation facet 2
body 50% body
neural tissue injury
open reduction
(spinal fusion) pure ligamentous injury
posterior fusion
Compression Fracture
50% injury posterior structure
neural tissue
91
Spinal Injuries
92
Spinal Injuries
Thoracolumbar region
1.! AP view spine spinal column
(scoliosis) psoas shadow psoas abscess
kidney renal stone, ureteric tone rule out
urinary tract
2.! AP view vertebra structure
( 6.14)
2.1! vertebral body
2
upper end plate
lower end plate
body
compression fracture
burst fracture body
2.2! disc space body
6.14 AP view of lumbar spine
disc space
degeneration intervertebral disc lumbur spondylosis
irregularity end plate infection
(vertebral infective spondylitis)
2.3! Spinous process fracture-dislocation
rotation force spinous process body
93
Spinal Injuries
! Compression Fracture
flexion injury
(anterior column) middle posterior
column ( 6.15)
motor vehicle accident
osteoporosis minor
injury
Spinal Injuries
12
3-5 body jacket
3 point fixation
Jewette
brace support
calcitonin osteoporosis
compression
fracture anterior column
50 % angulation 20
progressive deformity
! Burst Fracture
axial load body
anterior
middle column ( 6.17) middle column
retropulse-fragment
neural tissue
lateral view
anterior middle column AP view
pedicle (interpedicular distance)
body
6 .17 Burst fracture
pedicle
burst fracture
95
Spinal Injuries
! Chance Fracture
distraction injury spinal
column ligament
fracture lap seat belt
injury spinal column
failure 3 column
( 6.18)
stable fracture body jacket
ligament disc
space ligamentous injury
healing bone healing
progressive deformity
spinal fusion
combination force
(6 .19) injury 3 column
neural tissue damage
AP, lateral
spinal column AP
view lateral traslation
lateral view AP
96
Spinal Injuries
97
,
1.! (elasticity)
greenstick fracture, torus fracture, plastic deformation
2.! periosteum splint
reduction
3.! cell active osteogenic potential
birth fracture clavicle
1-2
4.! epiphyseal plate
ligament, joint capsule epiphyseal plate injury dislocation
5.! conservative treatment
6.! growth arrest
epiphyseal plate injury nonunion
7.! ossification center
growth plate
8.! (remodeling) accept alignment
angulation joint motion
9.!
98
3
1.! Greenstick fracture ( 7.1) incomplete fracture
greenstick fracture
diaphysis cortex
99
hypertrophic zone
Salter Harris epiphyseal plate injury 5 ( 7.3)
100
Remodeling of fracture
Remodeling
1.! 2 12
14
2.! metaphysis remodeling diaphysis
3.! (Bayonet apposition)
4.! deformity plane joint motion flexion, extension
varus, valgus
Remodeling
1.! intraarticular fracture
2.!
3.! displaced epiphyseal plate fracture
4.! diaphyseal fracture
1.! Faild close reduction
2.! Displace intraarticular fracture
3.! Displaced epiphyseal plate injury Salter-Harris type III, IV
4.! Children with multiple fracture or head injury
101
(conservative)
! Fracture of Clavicle
(birth fracture)
middle third
(pseudoparalysis)
crepitation (callus)
brachial plexus injury birth palsy
1-2 callus
5-6
arm sling 2-3
figure of eight
102
103
104
nondisplaced fracture
metaphysis lateral distal humerus long arm slab 4
displaced fracture metaphysis
lateral distal humerus displace intraarticular fracture
K-wire long arm slab 4-6
(pronation)
( 7.7) radial head
annular ligament
radial head
7.7 Pulled elbow
10-20
radial head
105
pulled elbow supracondylar fracture of
humerus
pulled elbow supracondylar fracture of humerus (SCFH)
pulled elbow
SCFH
1.
2.
2-3 7
4-5
12
3. radial head
lateral epicondyle
4.
pulled elbow
2-3
cortex metaphysis distal
radius
deformity
immobilization short arm slab 1-2
elastic bandage
2. Greenstick fracture incomplete fracture diaphysis
radius ulnar ( 7.2)
cortex
2
long arm cast 4-6
over correction periosteum
long arm cast 4-6
3. Plastic deformation
107
108
10 hip spica
6-8 1 .
overgrowth 10
plate screw intramedullary nail
injury growth plate
109
Open Fractures
8 Open Fractures
---------------------------------------------------------------------------------------------------------------------------------------
Open fractures
Open fractures
4
1.! Life preservation
2.! Limb preservation
3.! Avoidance of infection
4.! Functional preservation
.1878 Volkmann mortality rate 38.5% open fractures
1 open femoral fracture mortality rate 80%
open fractures
.1960 open fractures antibiotics ,
aggressive wound debridement , fracture stabilization delayed wound
closure
Definition
110
Open Fractures
contamination
fracture transverse, short oblique moderate
comminution
Type III 10 . extensive soft tissue damage
skin, muscle, neurovascular bundles dead bone soft tissue damage
contamination type I,II
Conditions type III open fracture
1.! Open segmental fracture wound size
high energy trauma
2.! Farm injuries comtaminate ,
3.! Gunshot wound high velocity closed range shotgun injuries
4.! neurovascular injury
5.! traumatic amputation
6.! open fractures 8
7.!
Type III subtype prognosis
Type III A.
Adequate soft tissue bone fracture site
extensive soft tissue damage, laceration flap
type Infection rate
4%
Amputation rate 0 %
Type III B.
extensive soft tissue damage periosteal stripping
expose bone (inadequate soft tissue coverage) contamination
type Infection rate
52 %
Amputation rate 16 %
111
Open Fractures
112
Open Fractures
Antibiotic Treatment
antibiotics
antibiotics gram positive bacteria cephalosporin cloxacillin
aminoglycoside open fracture type III contamination
high dose penicillin antibiotic
Debridement
open fractures
debridement procedure
1.! exploration of wound
2.! excision of devitalized tissue
3.! removal of foreign material and bacteria debridement
gentle handling of viable soft tissue
debridement superficial structure deep
structure
1. Skin puncture wound low velocity gunshot wounds
irrigation explore fracture
undisplaced fracture bone diameter
113
Open Fractures
Open Fractures
Stabilization of fractures
anatomic position
wound management early function
alignment circulation dead space hematoma
infection venous lymphatic return
Stabilization early motion early
mobilization joint stiffness, intra-articular adhesion, thromboembolic phonomena,
fat embolism syndrome
stabilization of fractures
1.! soft tissue
2.!
3.! alignment axis long bone anatomical reduction
intra-articular fractures
Plaster immobilization
open fracture
compartment syndrome type I
accept alignment
Pins and plaster
unstable open fractures tibia pin wire proximal
tibia distal tibia maintain length control rotation
stability external fixator
Skeletal traction and suspension
temporary stabilization definite stabilization open
fracture femur debridement proximal tibial traction
definite stabilization skeletal traction
1.! posterior
2.! maintain alignment
3.! stability wound healing, fracture healing
115
Open Fractures
116
Open Fractures
Open Fractures
Bone Grafting
open fracture soft tissue injury closed fracture bone
healing bone graft fill defect healing
autogenous cancellous bone graft bone graft open fracture
infection open fracture type I , type II intra-articular
fracture infection 6-8
bone graft soft tissue open
cancellous bone graft papineau technique
Rehabilitation
Elevation extermities
10 . arterial input distal
extremities compartment syndrome
Exercise involved limb
1.! muscle atrophy
2.! joint stiffness
3.! circulation, venous lymphatic return
Open Fractures
119
? ?
?
practical point
121
refer - reduce
- radial neck, radial head
- ulnar nerve palsy
11. Fracture shaft of radius and ulnar
Monteggia fracture, Galeazzi fracture
Displaced Night stick fracture
forearm reduction
alignment posterior long arm slab
refer
12. Non displaced Night stick fracture
long arm cast neutral 4
122
paper clip
4. Mallet finger
splint DIP joint 4-6
3-4 splint
deformity
refer - dorsal lip 30% articular surface volar
subluxation DIP joint
123
!Posterior dislocation
stable unstable
Alliss
Maneuver ( posterior dislocation) test stability
simple dislocation skin traction anterior dislocation
6
refer - (irreducible)
- test stability posterior wall fracture
- acetabular labrum
125
13.!Fracture of toe
buddy splint 2-3
subungual hematoma paper clip ()
2-4 hematoma release
pressure
! Spinal injury
spinal injury
(splint) secondary cord
damage spinal cord injury
cervical spine injury
spinal cord injury 8
high dose methyl prednisolone 30 mg./kg. IV bolus dose 15 IV drip 5.4
mg./kg. 23
spinal injury spinal brace
refer
compression fracture T-L spine
osteoporosis conservative treatment
1-2 Hormone calcitonin 50-100 IU 10
activity osteoclast bone pain compression
fracture Fowlers position
corset brace Jewette Chair back brace
3-4
128
130
! Open fractures
high energy injury
vital sign resuscitation
open fracture
1.! Bleeding
compressive bandage major vascular injury
compressive bandage vascular injury
anterior tibial artery compressive bandage 5
tourniquet proximal control
open fracture pelvis
bleeding per vagina vaginal packing
definite treatment
delayed primary wound closure
open fracture
1.! Wound irrigation contamination
2.! Compressive dressing ,
3.! Antibiotics prophylaxis and treatment
4.!
5.! NPO , film
132
Internet
e-mail consultation
digital attach file e-mail
(Teleradiology)
133
Complications of fracture
10 Complications of fracture
---------------------------------------------------------------------------------------------------------------------Complication
! Arterial injury
fracture-dislocation
arterial injury fracture-dislocation shoulder, supracondylar elbow
fracture, knee dislocation
arteriogram 6-8
! Nerve injury
arterial injury neurapraxia (physiologic
disruption) nerve injury cauda equina
compression (spinal fracture), axillary nerve (shoulder fracture-dislocation), radial nerve
(humerus fracture), ulnar nerve (medial epicondyle fracture), posterior interosseous
nerve (radial head, Monteggia fracture), sciatic nerve (posterior hip dislocation),
common peroneal nerve (lateral knee injury)
Nerve injury 3
1.! Neurapraxia physiologic disruption conduction block
134
Complications of fracture
2-6
2.! Axonotmesis axon endoneurium perineurium
motor end
plate 1
3.! Neurotmesis
nerve graft
! Cast syndrome
second part duodenum superior
mesenteric artery (body jacket) spinal fracture
hip spica cast femoral fracture small bowel
obstruction projectile vomiting
nasogastric tube
18-72
(restlessness) 39-40oc (tachypnea) 30 /
tachycardia 140 coma
long tract sign decerebrate rigidity 2-3
(patichiae) anterior chest, axilla, conjunctiva
135
Complications of fracture
FES
18-24
Severe
Rapid
Rapid
Rapid
Usually absent
Early
Head injury
6-10
Moderate
Slow
Slow
Slow
Usually present
Terminal
! Compartment syndromes
closed tissue compartment
1.! compartment
2.! compartment
1.1!bleeding, vascular injury, bleeding disorder
2.2! capillary permeability post ischemic swelling, crush injury, burn
136
Complications of fracture
10 .
arterial pressure
fasciotomy closed compartment
Complications of fracture
3
Elephants foot, Horses hoof Oligotrophic ( 10.1 )
2.! Avascular (atrophic) blood supply
4
Torsion wedge, Comminuted, Defect Atrophic ( 10.2 )
Complications of fracture
!Avascular necrosis
proximal scaphoid talus
mesenchymal cell
(resorption) remodeling
creeping substitution
(collapse)
relative
osteodensity disuse osteopenia
MRI
avascular necrosis
139
Complications of fracture
subchondral bone core decompression healing process
collapse
arthroplasty arthrodesis
Infection
open fracture open joint injury chronic
osteomyelitis septic arthritis open fracture open
joint injury debridement ( open
fracture)
(Tetanus) open fracture
5
0.5 cc. tetanus toxoid 5 0.5 cc.
tetanus toxoid 0.5 cc. tetanus toxoid 250 unit antitoxin
Fight bite human bite
anaerobic gram-negative rod
Eikenella corrodens Penicillin Ampicillin
Dog and Cat bites gram-negative coccobacillus Pasteurella
multocida Penicillin
Gas gangrene Clostridium perfringens anaerobes
toxin
12-24
subcutaneous emphysema
1.! shock
2.! high dose penicillin 3 4
3.!
140