Fracture & Dislocation

fractures 
A fracture is a structural breech in the normal continuity of bone.

Mechanism of injury 
1- Tubular bone: - Direct violence to the bone - Indirectly due to twisting or angulations 

2- Cancellous bone:
- may be fractured by compression

spiral. transverse. dorsal or volar. metaphysis. open or closed fracture).FRACTURE DESCRIPTION  Name of the injured bone  Location of the injury (eg. or epiphysis)  Orientation of the fracture (eg. diaphysis. Greenstick)  Condition of the overlying tissues (eg. . oblique.

reparative phase 3. remodeling phase . inflammatory phase 2.Fracture healing  Bone healing is usually divided into three slightly overlapping stages: 1.

 Subsequently.  Following a fracture.inflammatory phase  The initial inflammatory phase is dominated by vascular events. a hematoma forms. which begin to form new bone. multipotent cells are transformed into osteoprogenitor cells. reabsorption occurs of the 1 to 2 mm of bone at the fracture edges that have lost their blood supply  Next. .

which begins to form across the fracture site  Callus typically forms as a collar of new.  Callus is progressively replaced-from 3 weeks onwards in a child and 4 weeks onwards in an adult long bone-by mature (lamellar) bone with a Haversian structure strong enough to immobilise the fracture site and produce union.reparative phase  new blood vessels develop from outside the bone that supply nutrients to the cartilage. . endochondral bone around the fractured area.

 Clinical union Absence of tenderness on direct pressure over the fracture site Little or no pain when the fracture site is stressed by angulation or rotation Absence of movement at the fracture site  As a general rule  adult 4-8 weeks for fractures in cancellous bones 6-12 weeks for fractures in long bones  children approx half these times .

.Consolidation and remodeling phase  the new bone is reorganised so that its collagen fibres run in the lines of stress  The bone now returns to its original strength and the fracture is said to be consolidated.  For up to 2 years later. the fusiform mass of healing bone is gradually removed and the bone is further remodelled along its whole length in the lines of stress.

Tenderness.Deformity.History of trauma .Pain. abnormal movement (sure signs of fracture) .Diagnosis  Clinical: . swelling. swelling and bruising . inability to use the injured body part .

.Should always include the joints proximal and distal to the fracture .Look in the X-ray for: Presence of fracture The part of bone fractured The pattern of the fracture Presence and type of displacement . X-ray: A suspected fractured bone should be xrayed.X-ray should be taken in at least two planes (AP and lateral) .

Principles of fracture management  A) GENERAL TREATMENT . . . .Administer anti pain and splint all fractures before sending the patient for x-ray or referring.Always assess the status of distal circulation and neurological function.follow the ATLS system.

‚ needed only for displaced fractures . B) Local treatment of the fracture:I-Reduction ‚ manipulation of the fractured bone to restore normal or near normal anatomic position.

.g. e. Techniques of Reduction 1. Closed reduction ‚ Manipulation ‚ Traction 3. Open (Operative) reduction ‚ closed reduction fails ‚ very accurate reduction is required. a fracture which involves a joint surface ‚ the fracture has caused a vascular or (sometimes) a nerve injury. Using gravity 2.

Immobilization  The purpose of immobilization is to: prevent redisplacement of a reduced fracture decrease movement at the site of fracture and prevent further soft tissue injury relieve pain . II.

g plaster of Paris (POP) cast . Methods of Immobilization  1.Joints should be immobilized in a functional position .Is the safest and cheapest method of immobilization .Complications include joint stiffness and compartment syndrome.Immobilization should always include the two adjacent joints . External splints e. .

g. U-slab for humeral shaft fracture Skin traction: A method of applying traction using bandage. . 2. The maximum weight that can be applied is 2kg. usually used in children and temporarily in adults. Continuous traction Using gravity: e. Skeletal traction: Traction applied via a pin inserted into the bone distal to the fracture.

External fixation a rigid bridging device held in place by bone pins proximal and distal to the fracture mainly used in the management of open or infected fractures . 3.

pins and wires strongly indicated in patients with: multiple injuries pathological fractures associated neurovascular injury fractures where accurate reduction is required (e.g. screws. an elderly patient with a fracture of the neck of the femur. 4.g. those involving joints) ‚ the need to avoid a long period of immobilisation in bed. e. nails. ‚ ‚ ‚ ‚ . Internal fixation a method of operative fixation of fractures by plates.

 III . The patient is asked to move the injured part as much as the method of fixation allows. . The slight movement produced at the fracture site helps to: ‚ ‚ ‚ ‚ stimulate union decrease disuse osteoporosis prevent muscle atrophy minimise joint stiffness.Active movement and rehabilitation Rehabilitation starts immediately after treatment.

 Infection is the most feared complication of compound fractures and may cause delayed healing. non union.Open (compound) fracture  a fracture in which the fracture hematoma communicates with skin or mucous membrane. sepsis or even death.  It is a surgical emergency .

external fixation Delayed wound closure! NB: Never close a compound fracture immediately in an attempt to convert it to a closed one. Penicillin + Aminoglycoside should be given IV at least for 48 hrs.g.Principles of management  Early wound debridement and thorough      irrigation with saline Antibiotics: Broad spectrum e.g. You ll cause a severe anaerobic infection! . Tetanus prophylaxis Rigid immobilization with access to the wound e.

Arteries. Nerves and Viscera may be injured . Soft tissue Injuries .Complications of Fractures  I.

 II. It may be aggravated by application of tight bandages or circular POP casts on a freshly injured limb. Compartment syndrome Is a dangerously increased pressure within the enclosed fascial compartments of extremities. . Pallor or Pulselessness may develop later Early diagnosis and complete splitting of a tight bandage or circular POP cast may resolve the situation. Paresthesia. Fasciotomy is done if the above measures have failed. The high compartmental pressure causes Ischemia and necrosis of soft tissues in the compartment. Severe pain. especially with passive flexion of fingers is the earliest indicator. Paralysis. especially forearm and leg.

Usually complicates open fractures . III.Adequate debridement is the most critical factor in preventing infection. . Infection . .Chronic osteomyelitis may be the result.

Bone healing abnormalities Delayed Union ‚ Failure of a fracture to heal in the expected time period. E. . Non union ‚ Total failure of the fracture to heal with formation of a false joint between the fractured ends (pseudoarthrosis) Malunion ‚ Healing occurs with deformity Avascular necrosis ‚ Necrosis of part of the fractured bone occurs due to disruption of its vascular supply.g. IV. Femoral head.

Joint complications Joint stiffness Secondary Hemarthrosis osteoarthritis  VI. Systemic complications Usually follow polytrauma and major long bone fracture Include ARDS and fat embolism syndrome . V.

.  A subluxation is partial joint disruption with partial remaining but abnormal contact of articular surfaces.DISLOCATIONS  A dislocation is a total disruption of joint with no remaining contact between the articular surfaces.

Types of Dislocation  1. A force strong enough to disrupt the joint capsule and other supporting ligamentous structures dislocates a previously normal joint. .Traumatic dislocations This is a type of dislocation caused by trauma.

Septic hip dislocation . E. 2.g.Pathological /Spontaneous dislocation This is a type of dislocation which occurs when a pathological condition in the joint causes abnormality in the structural integrity of the joint.

Recurrent dislocation This is a dislocation which repeatedly occurs after trivial injuries due to weakening of the supportive joint structures  4.g. 3. Congenital hip dislocation .Congenital dislocation A type of dislocation which is present congenitally since birth. E.

 Associated soft tissue injuries should be looked for:  E.g.Diagnosis  The limb assumes an abnormally fixed position with loss of normal range of movement in the affected joint. Popliteal artery in knee dislocation Sciatic nerve in posterior hip dislocation  X-ray in various planes and views confirms diagnosis .

Management  Early reduction of the dislocation  Immobilizing the joint to allow time for the supporting structures of the joint to heal  Rehabilitation of the joint .

.AMPUTATIONS  An amputation is removal or excision of part or whole of a limb.

Dead limb (Gangrene) Atherosclerosis Embolism Major arterial injury Diabetic gangrene  2.g. Gas gangrene) or malignancies which can t be controlled by other local measures  3.Dead loss Severe soft tissue injury especially associated with major nerve injury. . which may occur in compound fractures.Indications  1.Deadly limb Life threatening infection (e.

trauma The vascularity of tissues Presence of infection Status of the joints Access to the various types of prostheses .Level of amputation  The choice for the level of amputation depends on: Age The nature and extent of the pathology e. Neoplasm.g.

 In the upper limb.  In the lower limb. attempt should be made to conserve every possible inch. . the most important factor is to try and conserve the knee joint whenever possible.

neuromas. . etc.Complications of amputation  Edema  Hematoma  Secondary and reactionary hemorrhage  Infection  Ischemic necrosis  Flexion contracture  Chronic pain-psychogenic.

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