Clinical program on basic principles of management of common fractures and dislocation

FractureDefinition: A fracture is a breach of the structural continuity of bone, this structural breach hence fracture, may also occur through cartilage, epiphysis & physis. It may be no more than a crack, a crumpling or a splintering of the cortex; more often the break is complete & the bone fragments are displaced.

DislocationDefinition: Dislocation means the joint surfaces are completely displaced & the articular surfaces are no longer in contact with each other. Subluxation means partial separation of the articular surfaces.

Common fractures & dislocations:Supracondylar fractureColles fractureFracture radius & ulnaFracture humerusFracture tibia & fibulaFracture femurFracture foot(tarsal, metatarsal & phalanges)Fracture hand(carpal, metacarpal & phalanges)Shoulder dislocationElbow dislocationHip dislocation

How fracture happen? Bone is relatively brittle, yet it has sufficient strength & resilience to withstand considerable stress.

Fracture results from:

A single traumatic incidenceRepetitive stressAbnormal weakening of the bone(a pathological bone)

In all fractures there is an element of soft tissue damage, either contusion or laceration, & in some cases, the soft tissue damage may be more important than the bone or joint injury.

Basic principles of management of fractureDiagnosis:

HistoryPhysical examinationInvestigation

Contd.B. Assesment:

General condition of the patientNature of fractureAffection of neurovascular bundleOther soft tissue inlury

Contd.C. Treatment: a)General- 1. Treatment of shock 2. Control of haemorrhage, if significant. 3.Relieve of pain, if severe. 4. Treatment of associated injury. 5. Prevention of infection if fracture is compound- * Cleaning & debridement of wound * Tetanus prophylaxis * Antibiotic * Treatment of skin wound 6. Prevention & treatment of complication.

Contd.b) Specific- 3R1. Reduction: Gravity- Collar & cuff Hanging cast Closed- Manipulation-reduction by hand traction- Surface Skeletal Fixed Balanced Open-2. Rest.3. Rehabilitation.

General scheme of fracture managementDefine fractureDetect complicationDoes the fracture need reduction?Is the fracture unstable or stable?How can the fracture be stabilized?Does the fracture need immobilization & for how long?How can the patient be best rehabilitated?

Possible method offracture treatmentProtection aloneImmobilize with external splint without reductionClosed reduction

Manipulation & traction followed by immobilization with external splint or traction.Open reduction & internal fixationExcision of fracture fragment.

Indications for operative treatment of fractureCompound fractureReduction of fractureStabilization of fractureTime factor-metastasis diseaseSoft tissue managementManagement of complication- Vascular injury Head injury

HistoryImportance:the history gives important clues to the type of trauma likely. The energy of trauma is related to the mass & square of the velocity. The direction of the trauma will also affect the injury that should be seeking. The important thing to remember is that if the trauma was severe enough to fracture or dislocate the skeleton, then it is highly likely that there was enough energy to cause a second or even third dislocation or fracture.

ContdThe following points should be noted during taking history from a patient:Age- # may occur at any age but there are some fractures which are common in specefic age group.

*Greenstick # in children *Colles # in postmenopausal womaen *# neck of femur in old ageHistory of traumaAmount & nature of violanceLocal painLoss of functionLoss of sensation

ExaminationDuring examination the key features are to make sure that the patients overall condition is stable by checking their airways, breathing & circulation before concentrating on the musculoskeletal injuries. The examination then should be systemic from top to bottom of the body, with complete exposure & care taken to check the patients back as well as their front. For each limb, be sure to check the distal circulation & neurology. Finally, it is important to record these findings.

ContdMusculoskeletal examination works on a simple system originally designed by Apley. It consists of four letter words dividedinto threes, The first stem is *look; *feel; *move. The second stem branching off from each of these stem is *skin *soft tissue *bone Finally move is divided into *active *passive *stability

LookSkin:Look once at the skin for:

*bruising & wounds- evidence of recent injury; *redness- signs of inflammation; *scars- the archaeology of injury; *sweating- loss of sweating may indicate nerve damage;Soft tissue: Look a second time at the soft tissue. Should look for-

*swelling- a cardinal sign of injury & inflammation; *wasting- signs of disuse & nerve damage, the archaeology of injury.Bones:Look a third time at the bones(shape of the skeleton). Should look for-

*deformity- unusual angles or joints held in unusual position.

FeelSkin:

* temperature *sensationSoft tissue:

*tenderness *lumps *circulationBone:

*bone outlines *joint margins

MoveActive:

The patient should move their own joints within the limit of pain. Better to use simple language to explain what we want them to do & if necessary should demonstrate the movement.Passive:

Should not take the range of movement without watching the patients face.Stability:

There are two type of stability; dynamic & static. Dynamic stability is provided by muscle power; static stability by ligaments & intact joint surfaces.

Pathological anatomyWith fracture above the deltoid insertion, the proximal fragment is adducted by pectoralis major, with fracture lower down the proximal fragment is abducted by deltoid. Injury to the radial nerve is common though fortunately recovery is usual.3% in adults mostly- 70 years- 80% female.At age 20 years&&: 80% &&&&&&&&&&male mainly due to RTA.

Contd.C/F: Painful, swollen & bruised. May be open fracture.Rx:

The weight of the arm with an external cast is usually enough to pull the fragments into alignments. A hanging cast is applied from shoulder to wrist with the elbow flexed suspended by a sling around the patients neck. The cast may be replaced 2-3 weeks later by a short cast (shoulder to elbow) or a functional polypropylene brace which is worn for a further 6 weeks. If alignment is not acceptable- open reduction & internal fixation DCP & screw.

Fracture tibia & ulnaMechanism of injury: A twisting force causes a spiral fracture of both leg bones at different levels, an angulatory force causes transverse or short oblique fracture.

Indirect injury- low energy Direct injury- high energy

Clinical features: deformity is usual. Carefully examined for signs of soft tissue damage, severe swelling, bruising, crushing or tenting of the skin, circulatory changes or absent pulse. Always alert for signs of impending compartment syndrome. Specially in upper third of femur.

RX: Closed stable- long leg plaster. open unstable- external fixator.

Management of tibial fracture

Type TreatmentUndisplaced, stable closed reduction possibleLong leg plaster then patellar tendon bearing braceDisplacedIntermedulary nailUnstable, reduction only achievable, openPlate & screwSevere soft tissue injury or lossExternal fixator

Compartment syndromeCommon in fracture tibia.Dx is by high index suspicion, when pain is excessive specially on passively extending the toes.Treatment must be undertaken quickly.Plaster must be split or removed (even if fracture position is lost) & if symptoms fail to improve, a fasciotomy must be performed.

Fracture femurC/F: Swelling & deformity, painful on movement, vascular or other injury.Emergency Rx: If shock, should be treated. And use splint before move. Definitive Rx:

In children- surface traction Adult- Locked intermedullary nail/skeletal traction.

Fracture foot, ankle & handAnkle: Simple undisplaced fracture can be treated with a moulded cast for 6 weeks.

Unstable injury: Internal fixation mandatory. Four guiding principles are: *Dont delay *Treat the entire injury *Reduce accurately *Check & maintain reduction *Think of compartment syndrome in foot fracture.

Contd.Foot:

Simple closed undisplaced fracture can be treated by moulded cast in dorsiflexion 4-6 weeks. Think of compartment syndrome.Hand:

simple closed undisplaced fracture can be treated by full plaster from below elbow to knuckle in the position safe immobilization (POSI) & a collar & calf sling apply.

Shoulder dislocation(Anterior)Mechanism of injury: Dislocation is usually caused by a fall on the hand. The humerus is driven forwards, tearing the capsules or avulsing the glenoid labrum.

external rotation & abduction.

C/F: Pain is severe, the patient supports the arm with opposite hand & is loath to permit any kind of examination. The lateral outline of the shoulder may be flattened.

The arm always be examined for nerves & vessels before reduction is attempted.

Contd.Rx of anterior dislocation:

Under G/A, the elbow is bent to 90 & held closed to body; no traction should be applied , the arm is slowly rotated laterally 75, then the point of elbow is lifted forwards & finally the arm is rotated medially, if fingers can touch opposite shoulder- Reduction compatible. The entire limb is fixed to the body by adhesive strapping for 3 weeks to prevent recurrent dislocstion.

Shoulder dislocation(Posterior)Mechanism of injury: Indirect force producing marked internal rotation & adduction causes dislocation. Fit or convulsion, electric shock, fall on the flexed abducted arm.C/F: The arm is held in medial rotation & is locked in that position. The front of the shoulder looks flat with that of prominent coracoidRx under G/A: The acute dislocation is reduced by pulling on the arm with the shoulder in adduction, a few mins allowed for the head humerus to disengage & then the arm is gently rotated laterally while the humeral head is pushed forwards.Fixed over the body as before for 3 weeks.

Dislocation of hip(posterior)Mechanism of injury: This occurs usually in a RTA, when someone seated in a truck or car thrown forwards, striking the knee against the dashboard, the femur thrust upwards & the femoral head is forced out of its socket.C/F: The leg is short & lies adducted, internally rotated & slightly flexed, like beauty contest position. Rx under G/A: An assistant steadies the pelvis & the surgeon starts by applying a traction in the line of the femur as it lies, & then gradually flexes the patients hip & knee to 90, maintaining traction, at 90of hip flexion, traction is increased & sometimes a little rotation is required to accomplish reduction.

Immobilization- surface/skeletal traction bar-3 weeks.

Dislocation of hip (anterior)C/F:

The leg lies externally rotated, abducted & slightly flexed.Rx:

Like posterior dislocation- While the hip is gently flexed upwards, it should be kept adducted an assistant then helps by applying lateral traction to the thigh.

Elbow dislocationUsually posterior.Should be reduced as early as possible.Fall on outstretched hand with the elbow in extension. C/F: The patient supports forearm with the elbow in flexion. The deformity is obvious. The bony landmark may be palpable & abnormally placed.

Contd.Rx under G/A:

Pull on the forearm while the elbow is slightly flexed with one hand sideway displacement is corrected. Then the elbow is further flexed while the olecrenon process is pushed forwards with the thumb unless almost fall flexion can be obtained, the olecrenon is not in the trochlear groove. LABS for 3 weeks.

D/D of pain in the upper limbCervical spondylosis (common)Carpal tunnel syndromeSupraspinatus tedinitisTennis elbowSecondary malignant disease of boneDe Quervains diseasePancoasts syndromeThoracic outlet syndrome

Fall on outstretched handDislocation of shoulder jointFracture of clavicleSupracondylar fracture of humerusDislocation of elbow jointColles fractureGreenstick fracture of radius & ulna in children

Supracondylar fracture (types)Type-1:

#undisplaced but radiograph carefully confirm this.Type-2:

Posteriorly angulated but posterior periosteum remaining intact.Type-3:

Completely displaced, with shortening & overlap the fragments.

Supracondylar fracture (in children)Common after fall on outstretched handRadiograph interpretation is difficultVarus or valgus malunion will not remodelTraction is safe early management while the swelling is settleBrachial artery occlusion requires immediate reduction & close observation.Compartment syndrome must be identified & treated only.

Forearm fractureMost are two bone fractureSingle bone fracture are either from a direct blow or combined with ajoint dislocation.Two bone fracture usually requires internal fixation as they are unstable.Single bone fracture need careful review of the joints at the both ends, as there may be an associated dislocation.

Forearm fractureMonteggia#: consists of a fracture of the ulna & dislocation of the superior radioulnar joint.Galeazzi#: Consists of a fracture radius & dislocation of inferior radioulnar joint.Rx: Both under G/A. Open reduction & compression plate-ulna & radius respectively. In children- Closed reduction.Smiths fracture: Just reverse to colles fracture.

a) ventral displacement b)ventral angulation c) medial angulation d) pronation.