Fracture and joint injuries

Bab 15
 Fracture and asosiated injuries
• Fracture discontinuity of the
bone/Structural brake in continuity
• Important check associate injuries involve :
– Brain
– Spinal cord
– Thorax or abdominal vicera
– Major artery
– Peripheral nerve
• Physical factor  producing fracture
– Normally  bone rigid and has a degree of elasticity/
flexibility
– Structure
• Cortical bone  withstand compression and shearing better than
withstand tension force  majority fracture from tension force
and there are example of force : bending, twisting and straight
pull “fracture”
– In children is like young tree that can accepted the force and produce
tension failure on the concave side “green stick”
– In the insertion may become failure on tension and prodce “avulsion”
• Cancellous bone  sponge like structure  more susceptible to
compression force than cortical bone  may produce
“compression fracture” or “ impacted “ on opposing fracture
surface
– In child may develop buckle or torus fracture
– Caustative force
• Direct to bone
• Indirect to bone  more frequently
 DISCRIBE FRACTURE
1. Site
Diphysis, metafisis, epipisis, or intra articular
2. Extent
Complete or incomplete(hairline fracture)
3. Configuration
Tranverse, obliq, spiral and comminuted
4. Relationship fracture fragment to each other
Undisplace or displace
5. Relation to eksternal environtment
Open or closed
6. Complication
Complicated or uncomplicated
• Associate injury to periosteum
– Osteogenic sleeve bone  important to healing
fracture
– Caracteristic of periosteum
• Thicker, stronger and more osteogenic during growing
year of childhood than in adult
• Thicker on muscle surrounded
• In child  hard to torn but easy to separated “intact
periosteal hinge” rapid healing in fracture
• In adult easily to torn, hard to separated
• Diagnosis
– Anamnesa
• History of fall, twisting injuries, direct blow, road
accident “mecanism injuries”
• Localize of pain and aggregate by movement
• Decrease of function involved part
• CREPITUS FRACTURE
– Examination
• Inspection general expression of pain and patient
protect the injuries part
• LOOK(Inspection localized)  swelling, deformity,
abnormal movement, on skin may be ecchymosis
• FEEL (palpation)  localize tenderness at site of
fracture
• Diagnostic imaging
– Using a radiolucen splint  does not seen in
image
– Rule of two
• Two joint
• Two view
• Two limb
*additional condition  take the photo after 1 or 2 week
after injury to see another related fracture
• Normal healing fracture
– Bone can healing without scar
• Change by it self (bone)
• Change by fibrous tissue
– At first condition on fracture
• Transforming GF B, Insulin GF, Platelet derived GF, and 7
bone morphogenetic proteins
• BMP  induction mesenchymal cell to produce bone at
fracture site and help by “Inter leukin” aka cytokin to
fracture repair
– There are 2 type of bone
• Cortical
• Cancellous
*they can healing in different ways
– Healing fracture in cortical bone/ diaphyseal
bone/ tubular bone
• Fracture  blood vessel torn  internal bleeding 
clotting vessel  distance between fracture site
osteocyte in lacuna (osteoid) loss their blood supply
“DIE” new “simultaneous process” bone
resorption and new bone deposition
• In undisplaced fracture of long bone may local internal
bleeding  torn of the artery nutrient and periosteal
sleeve  fracture haematoma
• If displace  periosteal sleeve will also torn and the
fragment also hit the soft tissue or major arteries 
make massive bleeding
– 1st Stage  Haematoma
• Take space on soft tissue around the fracture
• Osteogenic cell arise from the deep layer of
periosteum forming external callus
• Osteogenic cell ftom endoosteum  internal callus
*The osteogenic process more rapid than the neoplasm of bone
• At this stage the callus are not contain bone and
radiolucent, soft and almost like fluid in consistency
“new bone formation”
– 2nd Stage  Clinical union
• Internal and external callus become woven bone and
cartilage / endochondral ossification  callus become
firm “clinical union” but it not become the original
strength  at RO see that callus but the fracture line is
still apparent
– 3rd stage  stage of Consolidation
• Primary callus replaced by mature lamellar bone and excess
callus is gradually absorbed  bone shape become normal
and diameter
• Wolff law contribute on this stage
– 4th ADDITIONAL CONDITION INTERNAL FIXATION
• When fracture has osteosintesis bone doesn’t know it has
fracture  no stimulus for internal and external callus 
fracture healing occurs direct the cortex “primary bone
healing” cutting cone appreance (osteoclast in front,
osteoblast behind him and make bridging osteon)
• Stressed has bypass by the plate make the bone look like
porotic “disuse osteoporotic”  so the plate must be
removed to allow wolff law
• Healing fracture in cancellous bone/ metaphyseal
bone/ cuboidal bone
– Located in the flared metaphyseal of long bone and at
bodies at short bone as well as in pelvis and ribs
– Consist sponge like lattice of delicate interconnected
trabeculae.
– Healing proses more in the internal callus then in the
external callus, it because rich of blood supply, little
bone necrosis at fracture surface and there are a lot of
area contact at fracture site undisplaced fracture
more rapid healling then in cortical bonerich callus
on fracture site
– Cancellous bone has more stronge to force then
compression, and if there are a gap between 2 surface
of fracture may lead delayed union on it
• Healing fracture in Articular cartilage
– Different with bone, hyaline cartilage in joint
surface was extremely limited to heal when
they have a fracture may filled by fibrous tissue or
not heal degenerative arthritis and change joint
function (wear and tear)
• Healing fracture in Epiphyseal plate
– May risk the local growth disturbance
 Time requested for uncomplicated
fracture healing
• Age of the patient
– At birth healing rapid, by age less rapid and constant at adult life until
elderly
– It because related osteogenic activity of periosteum and endosteum
• Site and configuration of the fracture
– Become more rapid if surrounded by muscle
– Fracture at cancellous bone more rapid then cortical bone
– Large fracture surface (obliq/spiral) heal rapidly the transverse
• Initial displacement of the fracture
– If the periosteum slevee still intact  more rapidly heal periosteum
• Blood supply to fragment
– Having good blood supply make bone alive  heal rapid if no complication
– If 1 fragment only have good blood supply  the dead fragment must be
absorb first  after that it will be united  less rapid
– If 2 fragment dead it need longer time to heal
 Abnormal healing fractures
• Malunion  heal in normal expected time but
the positin with residual bony deformity (not
in the alignment )
• Delayed union  may heal in good position
but needs more time to heal it
• Nonunion  fail completely to heal
– May develop fibrous union  pseudoarthrosis
 Complication of fractures
• Fracture may develop complication at initial,
early and late
1. Initial
– Local :
• Skin injuries
– Without : abrasion, laceration, puncture wound, penetrating
missile wound, avulsion, loss of skin
– Within : penetration fracture fragment to the skin
• Vascular injuries
– Major artery  syok hypovolemic, division,contusion
– Major vein  syok hypovolemic,division,contusion
– Local haemorage external, internal (soft tissuehaematoma,
bodies cavity  intracranial haemorage, hemothorax,
hemoperitoneum, hamarthrosis
 – Neurological injuries
• Brain, spinal cord, peripheral nerves
– Muscular injuries
• Division (incomplete)
– Visceral injuries
• Thorax
• Intra abdominal
• Remote complication
– Multiple injuries
– Hemorrhagic shock
2. Early complication
– Local complication
• Sequelae of immidiate complication
– Skin necrosis, gangrene, volkmann ischemia, gas gangrene,
venous thrombosis, visceral complication
• Joint complication
– Infection (septic arthritis)
• Bony complication
– Infection (osteomielitis)
– Avascular necrosis
– Remote complication
• Fat embolism, pulmonary embolism, pneumonia, tetanus,
delirium tremens.
3. Late complication
– Local complication
1. Joint complication
– Stiffness
– Post trauma degenerative arthritis
 2. Bony complication
• Abnormal fracture healing (
malunion,delayunion,nonunion)
• Growth disturbance (epiphyseal injuries)
• Persisten infection (chronic osteomyelities)
• Post traumatic osteoporosis
• Sudeck post traumatic painful osteoporosis
• Refracture
3. Muscular complication
• Post traumatic myositis ossificans
• Late rupture of tendons
4. Neurological complication
• Tardy nerve palsy
- Remote complication
- Renal calculi
- Accident neurosis
 ATLS
BLS :
– Airway (obstruction)
– Breathing (respiratory arrest)
– Circulation (cardiac arrest or severe bleeding)
ATLS = BLS +
• Cardiac monitoring
• Defibrillation
• Administering intravenous fluid
• Medication
• Airway device
• Preliminary(Penanganan)care for patients with
fracture
– Time at accident and time for treatment must
immediate send to hospital
– Consider to 3 phase
• Outside hospital (resuscitation and first aid)
• Care during transportation
• Emergency care in a hospital
1. Immediate care outside hospital
• Rapid assessment situation + controlling ABC
1. Airway obstruction by tongue (drop back to
pharynx, aspiration of mucus, blood, etc) C spine
+ head tilt chin lift or jaw thrust
2. Breathing  Airway clear, resuscitation by mouth to
mouth is given if required
3. Circulation if cardiac arrest CPR 30:2, for several
bleeding  pressure the wound, also check internal
bleeding
4. Shock controlling hemorrhage + minimalize pain
5. Fracture and dislocation  splinted before moved to
minimalized pain + prevent injuries of ST
 2.Transportation
• Remove helmed + cervical spine protector has
been installed
• Using short spinal board protecting spine
• Moving to hospital by ambulant must fast and
skilled driver (protect injuries), and ambulant
must be include suction and oxygen inhaler
• Must give all information about patient to the
hospital
 3.Hospital
• Receive information from the team in ambulance
(prepare problem of the patient) and other
(patient, friend, police, ambulance driver)
“AMPLE” for triage
• A= allergies
• M=last medication before accident
• P=Past histories (disease)
• L=Last meal
• E=Event related to injuries ( Mechanism of
injuries)
1. Airway
– Obstruction may relives by suction and insertion
pharyngeal airway or tracheal intubation or
tracheostomy
2. Breathing (respiratory arrest)
– If airway restored, any tension pneumothorax 
mechanical assisted respiration
3. Circulation
– If cardiac arrest  CPR, electrical defibrillation should
considered
– For eksternal bleeding  may compressed or clamp
– For internal bleeding its danger situation, because it
may save blood inside like femur  save 1 lt-2lt, or even
in pelvis >2lt
*Shock prevention shock must treated first  after that 
treatment other injury
*vital sign must be monitored and recorded
 Responsibilities for care of the critical
injuries
• Fracture and dislocation
– After ABC done
– Examination all body system
– Check indication and contraindication
• Contraindication
– Fracture not too serious for medication
– Fracture not adequate of this method
– Fracture may be worse by this method
• Indication/goal
– Relieve pain,
– Obtain and maintenance position of fracture
– Allow bony union
– Restore function
• Specific Methods treatment of “CLOSE FRACTURES”
1. Protection alone (without reduction or immobilizations)
2. Immobilization by external splinting(POP)
3. Close reduction with manipulation(reduction POP
maintain ) most common methods
4. Closed reduction by traction followed by immobilization
• Traction may from skin traction (child) or skeletal traction
(adolescent)
5. Close reduction followed by functional bracing
6. Close reduction by manipulation by external skeletal
fixation
7. Close reduction by manipulation by internal skeletal
fixation (screwing from the skin)
8. Open reduction followed by internal skeletal fixation
9. Excision fracture fragment and replacement by
endoprosthesis
• Treatment for “OPEN FRACTURE”
– Complicated by bacteria contammination
infection
• Classification of open fracture
– Type 1 = clean wound, less than 1 cm
– Type 2 = laceration more that 1 cm
– Type 3 =
» A. Extensive ST damage, but adequate to covering bone
» B. Extensive ST damage, extensive periosteal stripping,
devascularized bone  graft
» C. Associated vascular injury requiring repair
*golden perion 6 - 7 jam
•
• Complication fracture treatment
– Skin complication
• Tattoo  abrasion
• Pressure lesion
– Bed score (decubitus ulcer)
– Cast score (cast ulcer)
– Vascular complication
• Traction and pressure lesion
• Volkmann ischemia
• Gangrene and gas gangrene
– Neurological complication
– Joint complication
• Infection
– Bony complication
• Infection
Dislocation and associated injuries
• For maintenance joint stability
– Good joint surface
– Intact fibrous capsule and ligament
– Protective muscle that move joint
• Dislocation  a structural loss of its stability
• 3 degree joint instability
1. Occult joint instability(arise at stress )
2. Subluxation  surface still contact but in abnormal position
3. Dislocation (luxation) total abnormal position, if there are
fracture facture - dislocation

*if the ligament tear may healed by fibrous tissue, in minor

joint 3 wk , inmajor joint  3 mount
• Treatment for joint injuries
– Contusion
• Synovial membrane  effusion, if vessel torn
hemarthrosis , in Ro maybe intra articular fracture
aspiration
– Ligamentous sprains  tear and local
hemorrhage swelling  immobilization
– Dislocation and subluxation  close manipulation
or open reduction
– Torn ligament  ASAP must be repair if ankle
lateral ligament, finger collateral ligament
immobilization, in elbow and hip immobilization
with position and reduce complication myositis
ossificans
• Muscle injuries
– Strain  chronic overstretching of a muscle or its
tendon due to overuse
• Open tendon injuries
– Immediate surgical repair function of joint
especially in hand(fleksor tendon )
• Close tendon injuries
– Sprain immobilization, if tear repair by
surgical