Fractures

 

Systemic complications

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

Fat embolism

Compartment syndrome

Non-union

 

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

Skin

Muscle

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

 

Pathological fractures

What is a pathological fracture

What diseases may cause a pathological fracture

 

Congenital

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

 

 

 

 

Fractures

 

What is a fracture?

 

What may cause a fracture?

 

 

 

Types

 

Closed.

 

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

 

Simple

 

 

Transverse

 

 

Oblique

 

 

Spiral

 

 

Displaced

 

 

Comminuted

 

 

Impacted

 

 

Displaced

 

 

Hairline

 

 

Crush

 

 

Avulsion

 

 

Depressed

 

Greenstick

 

Stellate

 

A history of the type of trauma is important

 

 

Clinical features

 

Local pain

 

Pain on stressing a limb

 

Impaired function

 

Swelling

 

Haematoma

 

Limb deformity

 

Abnormal positions or movement

 

Altered length of limb

 

Crepitus

 

 

 

 

Priorities

 

Whole patient management

 

 

 

 

Principles of management

 

Systemic stabilization.

 

Prevent / treat shock.

 

Pain management, local and systemic.

 

Prevent infection

 

Reduction.

 

Alignment of bones.

 

Surgical, external or internal fixation.

 

Conservative.

 

 

 

 

First aid and basic management

 

Systemic stabilization.

 

Immobilization.

 

Traction.

 

Cover open fractures and keep moist.

 

First aid measure to allow movement to hospital.

 

Back slab immobilisation technique.

 

Collar and cuff, sling.

 

 

 

 

Haemorrhage

 

Bones have a copious blood supply.

 

Normal blood volume and how much can be lost.

 

IVT, crystalline, 3 for 1.

 

Observations in haemorrhage.

 

 

 

Local complications

 

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.

 

Bone grinding.

 

Skin.

 

PNS, e.g. brachial plexus, radial nerve.

 

 

 

Systemic complications

 

Shock.

 

CNS.

 

ARDS - shock lung, fat embolism.

 

Rhabdomyolysis with myoglobinaemia and myoglobinuria.

 

 

 

Different age groups

 

Children

 

Older people

 

 

 

 

 

 

 

 

 

 

 

The healing process

 

Diet

 

Rest and immobilization

 

Interposed tissues

 

Proximity of bone ends

 

Diameter of bone

 

Blood supply

 

Local soft tissue injury

 

Inflammation

 

Infection

 

Nicotine

 

 

Physiology of healing

 

Periosteum.

 

Endosteum.

 

Osteoblasts, collagen synthesis.

 

Osteoclasts.

 

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.

 

Remodelling.

 

 

Bony pathology

 

Osteoporosis.

 

Osteomalacia, softening due or calcium or vitamin D deficiency.

 

Tumours.

 

How are pathological fractures treated?

 

Malignancies and bones

 

Osteosarcoma.

 

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

plexus.

 

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

 

Ligaments

 

 

Joints

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.

Fig. 4

 

 

 

Salter-Harris classification of growth plate fractures.

Salter-Harris classification of growth plate fractures.

Type I is a physeal fracture (complete separation of the growth plate from the metaphysis) with or without displacement. Type II, the most common, is a physeal fracture that extends through the metaphysis, producing a chip fracture of the metaphyseal corner, which may be very small. Type III is a physeal fracture that extends through the epiphysis. Type IV is a physeal fracture plus epiphyseal and metaphyseal fractures. Type V, the least common, is a compression fracture of the growth plate.

 

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

 

Compartment syndrome

What is compartment syndrome

How will you recognise compartment syndrome

How will compartment syndrome be treated