Priorities in trauma care
Is blood loss a problem from broken bones
Is pain usually a problem in fractures
Treatment of fractures
What first aid measures may be taken after a fracture
What are the principals involved in fracture management in hospital
What is meant by reduction of a fracture
How may reduction of a fracture be carried out
How may fractures be immobilised
What structures are responsible for pain generation
How would you usually treat pain from a fracture
Complications during healing
Infection and bones
What is osteomylitis
How may osteomylitis be caused
How is osteomylitis treated
Other tissue damage
What other tissues may be damaged in bony injuries
What particular complications may occur after a rib fracture
What particular complications may occur after a skull fracture
What particular complications may occur after a vertebrae fracture
What are the local and systemic complications of crush injuries
Blood vessels, haemorrhage and ischaemia, elbow and knee injuries may involve major vessels
What are primary and secondary soft tissue injuries
How would you recognise damage to tendons and ligaments
What is a sprain
The healing process
What factors are involved in the rate of bone healing
Age Blood supply
Diameter of bone Infection
Immobility Necrotic tissue
Interposition of soft tissues
Is diet important in the healing process
Is rest important in the healing process
Stages in bone healing
1. Haematoma Stage - usually there is an ischaemic area of bone near the fracture.
2. Cellular Proliferation - mitosis of periosteum and endosteum, forms a fibrous union.
3. Callus formation - osteoblasts lay down intercellular matrix of collagen and polysaccharides which soon become impregnated with calcium salts, forming immature "woven" bone or callus.
4. Consolidation - osteoblasts transform immature bone into mature bone with typical lamellar structure.
5. Remodelling - reformation of medullary cavity, bone strengthens along lines of force, at the expense of tissue outside the stress lines.
Trauma and diseases involving joints
Are joints often affected in trauma
What pathologies of joints to you frequently come across
How are these joint conditions treated
What is a pathological fracture
What diseases may cause a pathological fracture
Inflammatory e.g. Osteomyelitis
Neoplastic e.g. Benign, Primary, Secondary
Metabolic e.g. Osteomalacia, Osteoporosis, Paget`s.
How are pathological fractures treated
Malignancies and bones
What malignancies are associated with the bones
Disorders of bony metabolism
What common disorders of bone metabolism occur
Paget`s disease – softening and thickening of bone
Osteomalacia – adult rickets, softening of bone due to lack of vitamin D, calcium, phosphates
What is a fracture?
What may cause a fracture?
Open, e.g. open to air, bowel, body cavity.
Which observations may indicate an open fracture?
Is infection a problem in bone?
What is osteomyelitis?
Are closed fractures at risk from infection?
In what ways can bad management cause harm?
Descriptions of fractures
A history of the type of trauma is important
Pain on stressing a limb
Abnormal positions or movement
Altered length of limb
Whole patient management
Principles of management
Prevent / treat shock.
Pain management, local and systemic.
Alignment of bones.
Surgical, external or internal fixation.
First aid and basic management
Cover open fractures and keep moist.
First aid measure to allow movement to hospital.
Back slab immobilisation technique.
Collar and cuff, sling.
Bones have a copious blood supply.
Normal blood volume and how much can be lost.
IVT, crystalline, 3 for 1.
Observations in haemorrhage.
Secondary neurological injury
Vessels may be torn or compressed.
Observations for vascular damage / embarrassment.
Muscle, tendon, ligament injury.
Muscular damage - e.g. compartment syndrome, pain, fibrosis, loss of function.
Where is compartment syndrome most common?
Complications to rib fractures – pneumothorax.
Complications of skull fracture.
PNS, e.g. brachial plexus, radial nerve.
ARDS - shock lung, fat embolism.
Rhabdomyolysis with myoglobinaemia and myoglobinuria.
Different age groups
The healing process
Rest and immobilization
Proximity of bone ends
Diameter of bone
Local soft tissue injury
Physiology of healing
Osteoblasts, collagen synthesis.
Haematoma formation, fibrin.
Granulation tissue formation.
Cellular proliferation forms a fibrous union
Soft callous, fibrous tissue.
Mineralization of soft callus forms hard callus, (woven bone).
Ossification with mature lamellar bone.
Osteomalacia, softening due or calcium or vitamin D deficiency.
How are pathological fractures treated?
Malignancies and bones
Secondary tumours, breast, prostate, cervix, thyroid.
Trauma and diseases involving joints
Are joints often affected in trauma?
What pathologies of joints to you frequently come across?
How are these joint conditions treated?
Other tissue involvement
Damage or necrosis from pressure.
Muscles and Tendons - muscle involvement causes pain, tendons involve
loss of function.
Nerves - May be cut by broken bone or stretched at moment of injury,
(prognosis implications) e.g., radial nerve involvement or brachial
Blood Vessels - Elbow and knee - possible major arterial involvement.
ischaemic necrosis of muscle, (surgical correction < 6 hours)
Local Pressure - Bone and periosteum haemorrhage - haematoma
Depressed skull fractures
Depressed Rib Fractures
Fibrous - e.g., suture between bones of skull
Cartilaginous - e.g., pubic bones and between bodies of vertebrae
Synovial - e.g., hip
Types of synovial
Gliding eg., wrist or ankle
Hinge eg., elbow
Pivot eg., between 1st and 2nd cervical vertebrae
Condyloid allows movement in two directions eg., between wrist and forearm.
Saddle - like a condyloid with deeper articulating surfaces eg., between wrist and metacarpal bone of thumb.
Ball and Socket - Allows movement in all directions.
Growth plate fractures: Bone grows as tissue is added proximally by the growth (epiphyseal) plate, which is bordered by the metaphysis proximally and the epiphysis distally. The age at which the growth plate closes and bone growth ceases varies according to the bone, but the growth plate is closed in all bones by the end of puberty.
The growth plate is the most fragile part of the bone and thus is usually the 1st structure disrupted when force is applied. Growth plate fractures are classified by the Salter-Harris system (see Fig. 4: Fractures, Dislocations, and Sprains: Salter-Harris classification of growth plate fractures.. Disruption of future bone growth is common with types III, IV, and V and uncommon with types I and II.
Growth plate fractures are suspected in children with localized growth plate tenderness. These fractures are clinically differentiated from contusions by circumferential tenderness. In fracture types I and V, x-rays may be normal. If so, these fractures can sometimes be differentiated by injury mechanism (distraction [separation in longitudinal axis] vs compression). Closed treatment is usually sufficient for types I and II; ORIF is often required for types III and IV. Patients with type V injuries should be referred to a pediatric orthopedist because such injuries almost always lead to growth abnormalities.
POSTERIOR VIEW OF SKELETON
1) Parietal 2) Cervical vertebrae
3) Thoracic vertebrae 4) Lumbar vertebrae
5) Coccyx 6) Femur
7) Fibula 8) Tibia
9) Calcaneus 10) Occipital
11) Scapula 12) Ilium
13) Sacrum 14) Ischium
ANTERIOR VIEW OF SKELETON
1) Orbit 2) Mandible
3) Sternum 4) Xiphoid process
5) Costal cartilage 6) Os coxae
7) Illium 8) Pubis
9) Ischium 10) Frontal
11) Nasal 12) Maxilla
13) Clavicle 14) Ribs
15) Humerus 16) Vertebral column
17) Ulna 18) Radius
19) Sacrum 20) Coccyx
21) Carpals 22) Metacarpals
23) Phalanges 24) Femur
25) Patella 26) Tibia
27) Fibula 28) Tarsals
29) Metatarsals 30) Phalanges
Questions on fractures
What is crepitus
Why are fractures so painful
How may pain be reduced after a fracture
Why are backslabs used
Why should rings be removed
Why may a broad arm sling be used
What are the indications for a collar and cuff
What is compartment syndrome
How will you recognise compartment syndrome
How will compartment syndrome be treated