PRINCIPLES OF PRINCIPLES OF FRACTURESFRACTURES
Dr.David SamarooDr.David Samaroo MBBS,MSMBBS,MS
Department of Orthopedic Surgery Department of Orthopedic Surgery
Georgetown Public Hospital Corporation, Georgetown Public Hospital Corporation, University of Guyana School of Medicine.University of Guyana School of Medicine.
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Mechanism of InjuryMechanism of InjuryTypes of ForceTypes of Force
GENERAL CONSIDERATIONS IN MUSCULOSKELETAL GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMATRAUMA
Assessment & treatment,principles of splintingAssessment & treatment,principles of splinting Signs of a Fracture……dislocations,sprains/strainsSigns of a Fracture……dislocations,sprains/strains Classification of fracturesClassification of fractures ImagingImaging NonunionNonunion MalunionMalunion Complications of fracturesComplications of fractures
COST OF MUSCULOSKELETAL COST OF MUSCULOSKELETAL TRAUMATRAUMA
Trauma is the “neglected disease”Trauma is the “neglected disease” Leading cause of death for people aged 1 to 44 yrs Leading cause of death for people aged 1 to 44 yrs
of all races & social levelsof all races & social levels More than 100,000 persons in USA die from More than 100,000 persons in USA die from
accidents; 500,000 are permanently disabledaccidents; 500,000 are permanently disabled Cost over $40 billion per yearCost over $40 billion per year Generates over 3.5 million admissions to acute-Generates over 3.5 million admissions to acute-
care hospitals per yearcare hospitals per year Local figures unavailable,you are the ones to make Local figures unavailable,you are the ones to make
them availablethem available
Penetrating TraumaPenetrating Trauma
Compression (Blunt) TraumaCompression (Blunt) Trauma
Bending TraumaBending Trauma
HyperflexionHyperflexion
HyperextensionHyperextension
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Penetrating TraumaPenetrating TraumaCompression (Blunt) TraumaCompression (Blunt) TraumaBending TraumaBending Trauma
HyperflexionHyperflexionHyperextensionHyperextension
Severe Contusion of FootSevere Contusion of Foot
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Penetrating TraumaPenetrating TraumaCompression (Blunt) TraumaCompression (Blunt) TraumaBending TraumaBending Trauma
HyperflexionHyperflexion
HyperextensionHyperextension
CervicalCervical(C5-C6) (C5-C6) Fracture Fracture
DislocationDislocation
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Penetrating TraumaPenetrating TraumaCompression (Blunt) TraumaCompression (Blunt) TraumaBending TraumaBending Trauma
HyperflexionHyperflexion
HyperextensionHyperextension
Dorsal Dorsal Dislocation, Dislocation, Long Finger Long Finger Middle JointMiddle Joint(PIP Joint)(PIP Joint)
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Rotational TraumaRotational TraumaDistraction TraumaDistraction TraumaCrush TraumaCrush TraumaDeceleration TraumaDeceleration TraumaAcceleration TraumaAcceleration Trauma
Normal Normal Tibia Tibia Left Left
SpiralSpiral
FractureFracture
Tibia Tibia
RightRight
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Rotational TraumaRotational TraumaDistraction TraumaDistraction TraumaCrush TraumaCrush TraumaDeceleration TraumaDeceleration TraumaAcceleration TraumaAcceleration Trauma
Brachial plexus injury/Dislocation of Right Brachial plexus injury/Dislocation of Right ShoulderShoulder
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Rotational TraumaRotational TraumaDistraction TraumaDistraction TraumaCrush TraumaCrush TraumaDeceleration TraumaDeceleration TraumaAcceleration TraumaAcceleration Trauma
Crush Injury, LegCrush Injury, Leg
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Rotational TraumaRotational TraumaDistraction TraumaDistraction TraumaCrush TraumaCrush TraumaDeceleration TraumaDeceleration TraumaAcceleration TraumaAcceleration Trauma
Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma
Rotational TraumaRotational TraumaDistraction TraumaDistraction TraumaCrush TraumaCrush TraumaDeceleration TraumaDeceleration TraumaAcceleration TraumaAcceleration Trauma
Car struck from behind “accelerates” passengers, Car struck from behind “accelerates” passengers, producing an extension injury producing an extension injury
to the neck!to the neck!
Acceleration TraumaAcceleration Trauma
Mechanism of InjuryMechanism of InjuryTypes of ForceTypes of Force
Mechanism of InjuryMechanism of InjuryTypes of ForceTypes of Force
Direct ForceDirect Force Indirect ForceIndirect ForceTwisting ForceTwisting ForceHigh Energy ForceHigh Energy Force
DirectDirectMid-Shaft Fracture, FemurMid-Shaft Fracture, Femur
Mechanism of InjuryMechanism of InjuryTypes of ForceTypes of Force
Direct ForceDirect Force Indirect ForceIndirect ForceTwisting ForceTwisting ForceHigh Energy ForceHigh Energy Force
IndirectIndirectPosterior Dislocation, ElbowPosterior Dislocation, Elbow
Mechanism of InjuryMechanism of InjuryTypes of ForceTypes of Force
Direct ForceDirect Force Indirect ForceIndirect ForceTwisting ForceTwisting ForceHigh Energy ForceHigh Energy Force
TwistingTwistingSubtalar Dislocation, AnkleSubtalar Dislocation, Ankle
Mechanism of InjuryMechanism of InjuryTypes of ForceTypes of Force
Direct ForceDirect Force Indirect ForceIndirect ForceTwisting ForceTwisting ForceHigh Energy ForceHigh Energy Force
High EnergyHigh EnergyFractured PelvisFractured Pelvis
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
Assessment & treatment priorities are Assessment & treatment priorities are established according to type of injury, established according to type of injury, stability of vital signs, & mechanism of injurystability of vital signs, & mechanism of injury
Assessment:1)Rapid primary evaluationAssessment:1)Rapid primary evaluation 2)Restoration of vital function2)Restoration of vital function
3)Detailed secondary 3)Detailed secondary evaluationevaluation
4)Definitive care4)Definitive care
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
ABCs of Trauma Care:ABCs of Trauma Care: Airway maintenance (with c spine control)Airway maintenance (with c spine control) Breathing and ventilationBreathing and ventilation Circulation (with hemorrhage control)Circulation (with hemorrhage control) Disability (neurologic status)Disability (neurologic status) Exposure & environmental control (undress pt but Exposure & environmental control (undress pt but
prevent hypothermia)prevent hypothermia)
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
Pre-Hospital Principles:Pre-Hospital Principles: Joints above & below fracture should be immobilizedJoints above & below fracture should be immobilized Splints can be improvised with pillows, blankets, or Splints can be improvised with pillows, blankets, or
clothingclothing Immobilization doesn’t need to be absolutely rigidImmobilization doesn’t need to be absolutely rigid Overt bleeding should be tamponaded with dressing & firm Overt bleeding should be tamponaded with dressing & firm
pressurepressure Tourniquets should be avoided, unless it is obvious that pts Tourniquets should be avoided, unless it is obvious that pts
life is in dangerlife is in danger
Injury ManagementInjury ManagementSplinting Immobilizes the Injury Splinting Immobilizes the Injury Reduces PainReduces Pain
Prevents further damage to blood Prevents further damage to blood vessels, nerves and skin adjacent to vessels, nerves and skin adjacent to the injurythe injury
Decreases BleedingDecreases Bleeding
Facilitates TransportFacilitates Transport
Principles of SplintingPrinciples of Splinting Dress all woundsDress all wounds Immobilize the joints above and below a Immobilize the joints above and below a
suspected fracturesuspected fracture With injuries at or near joints, immobilize With injuries at or near joints, immobilize
the bones above and below the injurythe bones above and below the injury Stabilize the injury site during splint Stabilize the injury site during splint
application application
Principles of SplintingPrinciples of Splinting
Use gentle in-line manual traction to realign Use gentle in-line manual traction to realign displaced long bone fracturesdisplaced long bone fractures
Expect to encounter increased pain and some Expect to encounter increased pain and some resistance when attempting to realign a resistance when attempting to realign a deformed limbdeformed limb
Immobilize all suspected spinal injuries Immobilize all suspected spinal injuries in a in a neutral in-line positionneutral in-line position on a spineboard on a spineboard
Principles of SplintingPrinciples of Splinting
If the patient demonstrates major signs of If the patient demonstrates major signs of shock, align the limb as close to its normalshock, align the limb as close to its normal anatomic alignment as possible on a anatomic alignment as possible on a spineboard (immobilization of total body), and spineboard (immobilization of total body), and provide rapid transport provide rapid transport
Total Body ImmobilizationTotal Body Immobilization
When in doubt:When in doubt:
SPLINT!SPLINT!
Rigid SplintsRigid Splints Quick Splint Cardboard SplintQuick Splint Cardboard Splint
Ladder Splint SAM Splint Ladder Splint SAM Splint
Soft SplintsSoft Splints Air Splint Vacuum SplintAir Splint Vacuum Splint
Sling and Swathe Blanket Roll Sling and Swathe Blanket Roll
Traction SplintTraction Splint
When standard splints When standard splints are unavailable, are unavailable,
improvisation improvisation is better than doing nothing!is better than doing nothing!
UPPER UPPER EXTREMITYEXTREMITY
All fractures can be All fractures can be immobilized by immobilized by
securing the securing the extremity to the extremity to the
chest!chest!
LOWER EXTREMITYLOWER EXTREMITYAll fractures can be immobilized by All fractures can be immobilized by securing the injured extremity to the securing the injured extremity to the
opposite lower extremity!opposite lower extremity!
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
ORTHOPEDIC EXAMORTHOPEDIC EXAM Assess axial skeleton, pelvis, & extremitiesAssess axial skeleton, pelvis, & extremities Depends on overall central neurologic statusDepends on overall central neurologic status Assess for swelling, hematomas, open woundsAssess for swelling, hematomas, open wounds Palpate entire spine, pelvis, & each jointPalpate entire spine, pelvis, & each joint Exam pelvis by compression of iliac wings in mediolateral Exam pelvis by compression of iliac wings in mediolateral
direction & pubisdirection & pubis Must document neurologic status to fullest extent possible, Must document neurologic status to fullest extent possible,
motor & sensory, all major nerves & dermatomes inupper motor & sensory, all major nerves & dermatomes inupper & lower extremities& lower extremities
Must document all reflexes Must document all reflexes
Signs of a FractureSigns of a Fracture
TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb
Seven Seven Signs of FractureSigns of Fracture
TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb
Fractured PatellaFractured Patella
Seven Seven Signs of FractureSigns of Fracture
TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb
AngulatedAngulated Fracture, Fracture, Radius and UlnaRadius and Ulna
Seven Seven Signs of FractureSigns of Fracture
TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb
CrepitusCrepitusIn a complete fracture, In a complete fracture, the sounds of bone the sounds of bone
ends clicking or rubbing against each other;ends clicking or rubbing against each other; denotes an unstable fracture!denotes an unstable fracture!
Seven Seven Signs of FractureSigns of Fracture
TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb
Open Ankle FractureOpen Ankle Fracture
Seven Seven Signs of FractureSigns of Fracture TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb
False MotionFalse MotionThe unusual visual sensation of The unusual visual sensation of
observing motion at a long bone fracture observing motion at a long bone fracture site wheresite where
““there is no joint!” there is no joint!”
Seven Seven Signs of FractureSigns of Fracture TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb
Fracture, Right Clavicle Fracture, Right Clavicle Right Arm ProtectedRight Arm Protected
Seven Signs of FractureSeven Signs of Fracture
The presence of The presence of
any oneany one
of the of the
seven fracture signs just listed seven fracture signs just listed
is sufficient to assess this injury!is sufficient to assess this injury!
Types of Injury Types of Injury DislocationDislocation
Disruption of a joint such that the bone Disruption of a joint such that the bone ends are no longer in contactends are no longer in contact
Must have torn ligaments and joint Must have torn ligaments and joint capsulecapsule
Signs of DislocationSigns of Dislocation
TendernessTenderness Deformity (usually marked)Deformity (usually marked) Swelling and EcchymosisSwelling and Ecchymosis Loss of normal joint motionLoss of normal joint motion
Common DislocationsCommon Dislocations
ShoulderShoulderFingerFingerHipHipElbowElbow
Anterior Dislocation, Right ShoulderAnterior Dislocation, Right Shoulder
Common DislocationsCommon Dislocations
ShoulderShoulderFingerFingerHipHipElbowElbow
Dislocation, Middle Joint Dislocation, Middle Joint (PIP Joint), Ring Finger(PIP Joint), Ring Finger
Common DislocationsCommon Dislocations
ShoulderShoulderFingerFingerHipHipElbowElbow
Posterior Hip DislocationPosterior Hip Dislocation
Common DislocationsCommon Dislocations
ShoulderShoulder FingerFinger HipHip ElbowElbow
Posterior Elbow DislocationPosterior Elbow Dislocation
Types of InjuryTypes of Injury Fracture-DislocationFracture-Dislocation
A combined injury with joint A combined injury with joint dislocation and an adjacent bone dislocation and an adjacent bone fracturefracture
Fracture–Dislocation, AnkleFracture–Dislocation, Ankle
Types of Injury Types of Injury SprainSprain
Partial or completePartial or completetemporarytemporary joint dislocationjoint dislocation
Ligaments are torn Ligaments are torn partially or completelypartially or completely
May produce as much structural May produce as much structural damage as a dislocationdamage as a dislocation
Sprain, Left AnkleSprain, Left Ankle
Types of InjuryTypes of InjuryStrainStrain
““Muscle Pull”Muscle Pull”
Stretching or tearing of muscle, Stretching or tearing of muscle, or muscle fascia (covering)or muscle fascia (covering)
Occurs frequently in the lower Occurs frequently in the lower back secondary to poor posture back secondary to poor posture and poor abdominal muscle and poor abdominal muscle controlcontrol
Types of InjuryTypes of InjuryFractureFracture
• Any break in the continuity of a Any break in the continuity of a bonebone
• May vary from a simple crack to a May vary from a simple crack to a completely shattered bonecompletely shattered bone
FRACTURE FRACTURE CLASSIFICATIONCLASSIFICATION
Location of boneLocation of bone-Epiphyseal -Metaphyseal -Diaphseal-Epiphyseal -Metaphyseal -Diaphseal
Integrity of skin & soft tissue envelopeIntegrity of skin & soft tissue envelope
-Open vs. Closed-Open vs. Closed
Amount of displacementAmount of displacementNondisplaced AngulatedNondisplaced Angulated Displaced DistractedDisplaced Distracted
Incomplete/CompleteIncomplete/Complete
----
FRACTURE CLASSIFICATIONFRACTURE CLASSIFICATION
Orientation/Extension of Fracture LineOrientation/Extension of Fracture Line-Transverse-Transverse -Torus -Torus-Comminuted-Comminuted -Greenstick-Greenstick-Oblique-Oblique -Impaction-Impaction-Segmental-Segmental -Compression-Compression-Spiral-Spiral -Depression-Depression-Intra-articular-Intra-articular -Stress (Fatigue)-Stress (Fatigue)-Pathologic -Linear-Pathologic -Linear
Closed Fracture,Closed Fracture,
Base of ThumbBase of Thumb
ClosedClosed Dorsally Dorsally Angulated Angulated
Forearm FractureForearm Fracture
Open Fracture, TibiaOpen Fracture, Tibia
Open Fracture, ForearmOpen Fracture, Forearm
Open Fracture, ForearmOpen Fracture, Forearm
Open Fractures Are More Open Fractures Are More Serious!Serious!
Blood lossBlood loss
Potential contamination with Potential contamination with risk of infectionrisk of infection
Fracture ClassificationFracture Classification
Closed/OpenClosed/Open
Incomplete/CompleteIncomplete/Complete
Displaced/DisplacedDisplaced/Displaced
Incomplete Fracture, Incomplete Fracture, Distal RadiusDistal Radius
Complete Fracture, FemurComplete Fracture, Femur
Fracture ClassificationFracture Classification
Closed/OpenClosed/Open
Incomplete/CompleteIncomplete/Complete
Non-Displaced/DisplacedNon-Displaced/Displaced
Non-Displaced Fracture, Non-Displaced Fracture, Distal Tibia and FibulaDistal Tibia and Fibula
Displaced/Angulated Forearm Displaced/Angulated Forearm FracturesFractures
Types of FractureTypes of Fracture
Comminuted – fractured into more Comminuted – fractured into more than two segmentsthan two segments
Pathologic – fracture through Pathologic – fracture through diseased bonediseased bone
Epiphyseal – fracture passes through Epiphyseal – fracture passes through the growth platethe growth plate
Comminuted Femur FractureComminuted Femur Fracture
Types of Fracture
Comminuted – fractured into more than two segments
Pathologic – fracture through diseased bone
Epiphyseal – fracture passes through the growth plate
PathologicPathologicLytic lesion (darker = tumor) in Lytic lesion (darker = tumor) in proximal phalanx of finger, with proximal phalanx of finger, with
associated transverse fractureassociated transverse fracture
Other Types of Fracture
Comminuted – fractured into many pieces
Pathologic – fracture through diseased bone
Epiphyseal – fracture through the growth plate
Epiphyseal (growth-line) Fracture, Epiphyseal (growth-line) Fracture, Distal Femur Distal Femur
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
CONFIGURATION OF FRACTURES:CONFIGURATION OF FRACTURES: Intra-articular (fx line crosses articular cartilage & Intra-articular (fx line crosses articular cartilage &
involves joint)involves joint) Displaced (expressed in mm or cm or Displaced (expressed in mm or cm or %% in in
direction of displacement of distal fragment)direction of displacement of distal fragment) NondisplacedNondisplaced Angulated (expressed in degrees in direction of Angulated (expressed in degrees in direction of
apex)apex) Comminuted (more than 1 piece at one fx location)Comminuted (more than 1 piece at one fx location)
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
IMAGING STUDIES:IMAGING STUDIES: Polytrauma pts: c-spine, chest, pelvisPolytrauma pts: c-spine, chest, pelvis Long bone fx requires complete evaluation of Long bone fx requires complete evaluation of joint joint
proximally & distally to fxproximally & distally to fx Long bone x-rays, minimum of 2 views Long bone x-rays, minimum of 2 views AP & LateralAP & Lateral CT scans visualize complex fx patterns esp with joint CT scans visualize complex fx patterns esp with joint
involvementinvolvement MRI scans give soft tissue detailsMRI scans give soft tissue details Bone scan: indicative of blood flow & therefore of bone Bone scan: indicative of blood flow & therefore of bone
formation or destructionformation or destruction
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
““Clearing” the Cervical Spine:Clearing” the Cervical Spine: X-ray: A-P views, Lateral views, Open mouth X-ray: A-P views, Lateral views, Open mouth
odontoid viewodontoid view Open mouth: lateral masses of C1 should line up Open mouth: lateral masses of C1 should line up
with body of C2with body of C2
Must see down to C7, if can’t then Swimmer’s Must see down to C7, if can’t then Swimmer’s view, lateral cervical spine x-ray with arm abducted view, lateral cervical spine x-ray with arm abducted & elevated& elevated
May need flex/ext views to determine ligamentous May need flex/ext views to determine ligamentous stabilitystability
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
““Clearing” the Cervical Spine:Clearing” the Cervical Spine: Amount of total overhang of C1 over C2 should be Amount of total overhang of C1 over C2 should be
less than 3 mmless than 3 mm
Lateral view, anterior border of bodies of cervical Lateral view, anterior border of bodies of cervical segments should describe an arcsegments should describe an arc
No diastasis of spinous processesNo diastasis of spinous processes
Joints & facet joints should all be visibleJoints & facet joints should all be visible
Watch orientation from one cervical spine level to Watch orientation from one cervical spine level to another, r/o cervical fx, jumped facets, or dislocationsanother, r/o cervical fx, jumped facets, or dislocations
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
NONUNION:NONUNION:Nonunion: fx that fails to show progressive healing ,there are permanent radiologic Nonunion: fx that fails to show progressive healing ,there are permanent radiologic
signs the situation is permanentsigns the situation is permanent
CLASSIFICATION OF NONUNIONS:CLASSIFICATION OF NONUNIONS: Hypertrophic: “elephant’s foot ”, “horse’s foot ”Hypertrophic: “elephant’s foot ”, “horse’s foot ”
flared out with viable bone ends,fracture visible ,fracture filled with cartilage and flared out with viable bone ends,fracture visible ,fracture filled with cartilage and fiberous tissuefiberous tissue
Atrophic: nonviable bone ends,rounded,osteoporoticAtrophic: nonviable bone ends,rounded,osteoporotic
If left untreated, may develop into pseudoarthrosis (false joint)If left untreated, may develop into pseudoarthrosis (false joint)
Causes of non unionCauses of non union
GeneralGeneral
SpecificSpecific
Diastasis of fx fragmentDiastasis of fx fragment
Compromise blood supplyCompromise blood supply
Excessive motionExcessive motion
InfectionInfection
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
CAUSES OF NONUNION:CAUSES OF NONUNION:
1) General: age, nutrition, steroids, anticoagulants, radiation, burns, 1) General: age, nutrition, steroids, anticoagulants, radiation, burns, immunosupression -predisposure to nonunionimmunosupression -predisposure to nonunion
2)Diastasis of fx fragment2)Diastasis of fx fragment
a. Soft tissue interpositiona. Soft tissue interposition
b. Distraction from traction or internal fixationb. Distraction from traction or internal fixation
c. Malposition d. Loss of bonec. Malposition d. Loss of bone
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
3)Compromised blood supply3)Compromised blood supply
a. Damage to nutrient vesselsa. Damage to nutrient vessels
b. Stripping or injury to periosteum & muscleb. Stripping or injury to periosteum & muscle
c. Free fragments; severe comminutionc. Free fragments; severe comminution
d. Avascularity due to internal fixation devicesd. Avascularity due to internal fixation devices
CAUSES OF NONUNIONCAUSES OF NONUNION:
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
CAUSES OF NONUNIONS:CAUSES OF NONUNIONS:
4) Excessive motion: inadequate immobilization4) Excessive motion: inadequate immobilization
5) Infection5) Infection
a) Bone death (sequestrum)a) Bone death (sequestrum)
b) Osteolysis (Gap)b) Osteolysis (Gap)
c) Loosening of implants (motion)c) Loosening of implants (motion)
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
NONUNION OF FRACTURES:NONUNION OF FRACTURES: Delayed union: fx that has not gone on to full bony Delayed union: fx that has not gone on to full bony
healing after 6 monthshealing after 6 months Areas prone to nonunion:Areas prone to nonunion:
Distal tibial diaphysisDistal tibial diaphysis Proximal diaphysis of 5Proximal diaphysis of 5thth metatarsal metatarsal Segmental fxSegmental fx Transcervical hip fx,scaphoid,talusTranscervical hip fx,scaphoid,talus
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
TREATMENT OF NONUNIONS:TREATMENT OF NONUNIONS: Correction of cause, if possibleCorrection of cause, if possible Stabilization of bone endsStabilization of bone ends Eradication of infectionEradication of infection Restoration of blood supplyRestoration of blood supply Surgical excision of interposing tissuesSurgical excision of interposing tissues Bone graft of fracture gaps at time of internal Bone graft of fracture gaps at time of internal
fixationfixation
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
MALUNION OF FRACTURE:MALUNION OF FRACTURE: Fx that has healed with unacceptable amt of Fx that has healed with unacceptable amt of
angulation, rotation,or overridingangulation, rotation,or overriding Shortening is better tolerated in upper ext than Shortening is better tolerated in upper ext than
lower extlower ext Angular deformity better tolerated in humerus than Angular deformity better tolerated in humerus than
femur or tibiafemur or tibia Shortening more than 1 inch is poorly tolerated in Shortening more than 1 inch is poorly tolerated in
lower extremitylower extremity
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
COMPLICATIONS:COMPLICATIONS: Compartment SyndromeCompartment Syndrome Acute Respiratory Distress Syndrome (Fat Acute Respiratory Distress Syndrome (Fat
Embolism Syndrome)Embolism Syndrome) Thromboembolic DiseaseThromboembolic Disease AtelectasisAtelectasis Ectopic (Heterotopic) Bone FormationEctopic (Heterotopic) Bone Formation
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
COMPARTMENT SYNDROME:COMPARTMENT SYNDROME: Pathologic developments in a closed space in body Pathologic developments in a closed space in body
caused by buildup of pressurecaused by buildup of pressure Pressure rises from edema or bleeding within Pressure rises from edema or bleeding within
compartment, compromising circulation to compartment, compromising circulation to compartment, can result in necrosis of muscle & compartment, can result in necrosis of muscle & nerve damagenerve damage
Causes: Fracture, soft-tissue injury, arterial injury, Causes: Fracture, soft-tissue injury, arterial injury, burn, abnl external compression from burn, abnl external compression from immobilization immobilization
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
COMPARTMENT SYNDROME:COMPARTMENT SYNDROME: Characteristics: PainCharacteristics: Pain
PulselessnessPulselessness
PallorPallor
ParesthesiasParesthesias
ParalysisParalysis
-Pulses generally remain intact until late-Pulses generally remain intact until late
-Paresthesias occur only when significantly advanced-Paresthesias occur only when significantly advanced
-Paresis, if present, is an unreliable finding-Paresis, if present, is an unreliable finding
-Pain with passive stretching is subjective-Pain with passive stretching is subjective
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
COMPARTMENT SYNDROMECOMPARTMENT SYNDROME Pressure is key componentPressure is key component Palpation of soft compartment doesn’t rule out Palpation of soft compartment doesn’t rule out
compartment syndromecompartment syndrome Intracompartmental pressure readings greater than Intracompartmental pressure readings greater than
30-40 mmHg are indications for fasciotomy30-40 mmHg are indications for fasciotomy Late fasciotomy may result in muscle damage or Late fasciotomy may result in muscle damage or
possible necrosis with resulting infectionpossible necrosis with resulting infection
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
COMPARTMENT SYNDROME:COMPARTMENT SYNDROME: Forearm: Extensile volar incision to permit Forearm: Extensile volar incision to permit
complete release, including carpal tunnel distally complete release, including carpal tunnel distally & lacertus fibrosis proximally; Dorsally, a & lacertus fibrosis proximally; Dorsally, a longitudinal incision is usedlongitudinal incision is used
Calf: Two incisions are used to release the four Calf: Two incisions are used to release the four compartments of legcompartments of leg
Longitudinal incision over anterior intermuscular Longitudinal incision over anterior intermuscular septum for anterior & lateral compartmentsseptum for anterior & lateral compartments
Posteromedially, second incision for superficial & deep Posteromedially, second incision for superficial & deep posterior compartmentsposterior compartments
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
Fat Embolism Syndrome:Fat Embolism Syndrome: Special ortho manifestation of ARDSSpecial ortho manifestation of ARDS Caused by release of marrow content into circulation e.g. Caused by release of marrow content into circulation e.g.
s/p fractures/p fracture Lungs show fat droplets, usually diffusely distributed Lungs show fat droplets, usually diffusely distributed
throughout pulmonary vasculaturethroughout pulmonary vasculature Can occur when medullary canal of a long bone is Can occur when medullary canal of a long bone is
pressurized during IM alignment jigs of TKApressurized during IM alignment jigs of TKA Dx: Decrease in arterial Po2, Increase systemic Pco2, Dx: Decrease in arterial Po2, Increase systemic Pco2,
infiltrates on chest X-ray, presence of petechiae, & mental infiltrates on chest X-ray, presence of petechiae, & mental confusionconfusion
Rx: Minimize hypoxemia with ventilatory supportRx: Minimize hypoxemia with ventilatory support
GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA
HETEROTOPIC BONE FORMATIONHETEROTOPIC BONE FORMATION Occurs in 10% of trauma casesOccurs in 10% of trauma cases May cause pain or joint motion restriction or ankylosisMay cause pain or joint motion restriction or ankylosis Without head trauma can be seen on x-ray 1-2 months after Without head trauma can be seen on x-ray 1-2 months after
traumatrauma Much more common in head injury pts, release of humeral Much more common in head injury pts, release of humeral
modulatorsmodulators Resection may be indicated by 6 months if NL alkaline Resection may be indicated by 6 months if NL alkaline
phosphatase & mature x-ray appearancephosphatase & mature x-ray appearance May benefit from low dose radiation (7Gy) & May benefit from low dose radiation (7Gy) &
indomethacin for 3-6 weeksindomethacin for 3-6 weeks