Fractures and Dislocations



Introduction to Fractures and Dislocations

Canadian Association of Physician Assistants (CAPA) Conference

October 29, 2016

Winnipeg, MB

Dr. Chris Graham MD, FRCSC, Assistant Professor University of Manitoba, Orthopedic Trauma

Definitions:

Fracture – the loss of structural integrity of a bone.

Dislocation – loss of joint surface contact/congruity

ORIF – open reduction (direct manipulation of bone fragments), internal fixation (application of surgical implant to stabilize the bone)

Etiology - macrotrauma (Force > bone strength)

- microtrauma (stress#)

- pathologic (abnormal bone)

Classification – aids in communication and study of fractures. May guide treatment

- etiology - mechanism

- location - what bone, what part of the bone

- pattern – transverse, oblique, spiral, comminuted

- Open vs closed ** “compound” now rarely used so don’t use it.

Clinical features – Pain, tenderness

Deformity

Loss of function

Abnormal motion

Crepitus

Bruising, Fracture blisters

Bleeding if open- if unsure then ask someone!!

Management Goals– emergency – diagnosis and treatment

Once stable – definitive diagnosis and other injuries then definitively treat

Rehabilitation and restoration of function

1. Field management – ABC’s of trauma

Cursory assessment – open vs. closed, deformity, perfusion, compartments

Splint – reassess circulation after

Dress open wounds – sterile, moist bandage and pressure

Transport

2. Emergency Room – ABC’s

History – mechanism compatible with Hx? Symptoms (neurologic, evolving?)

Examination – r/o other, not so obvious injury. 1st exam most NB- vascular, neulologic, skin, compartments

General History & Physical

Splint

Open – update tetanus, give antibiotics – usually 1st generation Cephalosporin but should be broad spectrum

Dress wound

Analgesia

Xrays – rule of 2’s – 2 joints (above and below the #), 2 views (a-p and lat.), 2 times (before and after reduction)

Some regions require special views where lateral not as easy e.g. shoulder – a-p and axillary lat.

-----Always get the views/imaging you need----- or you’ll miss something.

Other imaging – CT- bone, joints, pre-op planning, soft tissue

MRI – bone, occult fracture, infection, tumors

Bone scan - tumors, metastasis, infections, occult fracture

U/S - rarely

Interpreting Xrays:

Very NB to facilitate communication and planning treatment. Be systematic and thorough, you are responsible for everything on the film!

Confirm Pt, part of body etc.

Bone and location – diaphysis, metaphysis, epiphysis, joint

Pattern – transverse, oblique, spiral, segmental, comminuted – bone as a material breaks in a predictable manner based on amount, direction and duration of force.

Displacement – “L.A.R.T.” Length – shortening

Angulation – describe in terms of the apex direction, not the direction of the distal fragment

Rotation

Translation – can use cortical diameter as a measure

e.g. “a midshaft transverse diaphyseal tibia fracture with 2 cm of shortening, 100% displaced, angulated 30 degrees apex medial with minimal comminution.”

3. Plan definitive management:

Reduction – is it needed, if so how? – Closed or open, sedation or in the OR

Stabilization – must last for as long as it takes for the bone to heal, all hardware eventually fails if the bone doesn’t heal

Splint, cast, traction all closed devices

Plates and screws, intramedullary nails, wires are open devices

External fixator

Indications for open reduction and internal fixation: some are relative. There are fracture and patient factors that are considered.

Failure of closed methods to obtain or maintain a reduction

Displaced intraarticular fractures

Open fractures

Pathologic fractures (sometimes)

Associated with a vascular injury

Polytrauma

Dislocations: loss of the normal joint surface apposition

Must evaluate/document pre and post reduction – neurologic and vascular status

Xray pre and post reduction – need to ensure you’ve achieved the reduction

Immediate reduction is often warranted---don’t need an orthopedic surgeon if it is straightforward. Generally need good sedation and analgesia, long sustained traction.

Open reduction in OR if closed fails.

Assess ROM for arc of stability e.g. elbow

Generally, early, protected ROM after short period of immobilization

Exclude associated fractures before if possible

Delay may lead to Avascular necrosis (AVN) – hip

Vascular injury – elbow, knee

Special Fractures: open, pathologic, stress, children

1. Open fractures: graded by the size of wound, amount of soft tissue injury and periosteal stripping (Gustillo – Anderson).

Grade 1 - wound up to 1 cm, usually inside to outside mechanism. Little contamination and closes easily

Grade 2 – 2-10cm long, more contamination and periosteal stripping

Grade 3 – a- extensive comminution

Large soft tissue injury, crushing, high velocity GSW

Contaminated

Wound still closable

-b- as above but need soft tissue reconstruction – usually a flap/skin grafting

-c- anything with a vascular injury

Emergency management. (Easy and should be done in a timely fashion)

Pick off any large/gross contamination

Sterile moist dressing – one look only, picture if possible

Reduce # and splint – protruding bone under skin if possible

Tetanus update

IV antibiotic

Xrays

Call Ortho sooner than later. After? 6-8 hrs infection rate increases

Once in the OR – Thorough I&D

Definitive stabilize if low grade/ clean

If high energy/ gross contamination consider 2nd look in 48 hrs. Ex-fix, splint to provisionally stabilize or allow access to soft tissues.

2. Pathologic fractures –# through abnormal bone

Mechanism often low energy, abnormal mechanism

May report local pain in the area prior to #

Look for any underlying pathology esp. if low energy, suspect mechanism, Hx of condition that may result in pathologic bone.

Causes include: Metabolic bone disease (osteoporosis, osteomalacia, Paget’s, renal osteodystrophy)

Tumor (malignant, benign, primary or mets. Most common is mets from – breast, prostate, thyroid, renal, lung)

Infection (pyogenic, TB, fungus)

Investigations: the cause------may be extensive workup

Advanced Imaging

Image the whole bone

Bone scan – place to biopsy, other areas involved

Labs: watch for hypercalcemia

ESR, CRP, CBC, renal and hepatic, electrophoresis

ORIF or operative stabilization may/usually required.

Prophylactic stabilization in impending # may be required. Workup pre-op and have a diagnosis and plan or operation/biopsy may change the stage from low to high and compromise the prognosis.

3. Stress fractures – due to microtrauma

Hx of repetitive or new activity

Pain before #

May be difficult to see on x-ray – use other modalities if suspect (bone scan, CT, MRI)

Sometimes managed non-op

Special locations should be managed operatively due to unlikely healing or consequences of displaced # (e.g. femoral neck, some tibia)

4. Fractures in children - common

Bones are more elastic so see greenstick/bent bones

Growth plates are a weak point so this is unique to children. Possibility of a growth plate arrest may lead to angular/length deformity. Some # should be followed to skeletal maturity.

Periosteum is thick, may impede reduction

Healing is very fast compared to adults. Sometimes ½ the time.

Pure dislocations are rare. Watch for growth plate separation! esp. if the epiphysis has not yet ossified.

Growth of the bone can correct some residual deformity( remodeling). More so if close to the growth plate, younger child, deformity is in the plane of motion of the limb. (e.g. bayonette forearm)

ORIF not necessary as often as in adults. Often use K-wires, splinting, traction as kids recover faster, bones unite faster, joints don’t get as stiff.

Complications of Fractures:

Local: Skin necrosis

Neurovascular injury

Infection

Compartment syndrome

Later: Malunion, delayed or nonunion

Infection (open or operated on)

AVN (hip, scaphoid, talus)

Complex Regional Pain Syndrome (CRPS,or RSD)

Loss of function – post traumatic arthrosis, stiffness of joints

Complications of Fracture Management

Cast Tight – compartment syndrome

Poor padding, technique – pressure ulcer

Joint stiffness

Osteoporosis of region (clinical significance unknown)

Skin traction Skin slough

Bed sores

External fixation Pin tract infection, loosening

Delayed, mal-/nonunion

Internal fixation Infection

Delayed/nonunion

Loss of fixation and Malunion

Neurovascular injury

The End.

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