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

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

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

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

reparative phase
 new blood vessels develop from outside the

bone that supply nutrients to the cartilage, which begins to form across the fracture site  Callus typically forms as a collar of new, endochondral bone around the fractured area.  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.

 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.

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

 X-ray: A suspected fractured bone should be xrayed.

- X-ray should be taken in at least two planes (AP and lateral) - 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

Principles of fracture management

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

 B) Local treatment of the fracture:I-Reduction

manipulation of the fractured bone to restore normal or near normal anatomic position. needed only for displaced fractures

 Techniques of Reduction
1. Using gravity 2. Closed reduction
Manipulation Traction

3. Open (Operative) reduction

closed reduction fails very accurate reduction is required, e.g. a fracture which involves a joint surface the fracture has caused a vascular or (sometimes) a nerve injury.

 II- 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

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

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

 3. 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

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

 III - Active movement and rehabilitation

Rehabilitation starts immediately after treatment. 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.

Open (compound) fracture

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

Principles of management
 Early wound debridement and thorough     

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

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

 II. Compartment syndrome

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

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

 IV. Bone healing abnormalities

Delayed Union
Failure of a fracture to heal in the expected time period.

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. E.g. Femoral head.

 V. Joint complications
Joint stiffness Secondary Hemarthrosis osteoarthritis

 VI. Systemic complications

Usually follow polytrauma and major long bone fracture Include ARDS and fat embolism syndrome

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

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

 2- 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. E.g. Septic hip dislocation

 3- Recurrent dislocation
This is a dislocation which repeatedly occurs after trivial injuries due to weakening of the supportive joint structures

 4- Congenital dislocation
A type of dislocation which is present congenitally since birth. E.g. Congenital hip dislocation

Diagnosis
 The limb assumes an abnormally fixed position with loss of normal range of movement in the affected joint.  Associated soft tissue injuries should be looked for:  E.g. 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.

Indications
 1- Dead limb (Gangrene)
Atherosclerosis Embolism Major arterial injury Diabetic gangrene

 2- Deadly limb
Life threatening infection (e.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.

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

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

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