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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