UNIT 2

INTRODUCTION TO ORTHOPAEDICS AND TRAUMATOLOGY.

Unit Objectives

 By the end of this unit, you will have achieved the following objectives;
 1. Clerk an orthopedic or trauma patient appropriately
 2. Apply the principles of management of orthopedics
 3. Classify fractures and outline their clinical and radiological features
 4. Apply the principles of fracture management in trauma patients
 5. Manage open fractures
 6. Identify complications of fractures
 7. Demonstrate understanding of special features of fractures in
children
 8. Manage joint injuries
Introduction

 Orthopaedics is the branch of surgery that deals with diseases and

injuries of the trunk and limbs.
 It deals with conditions affecting bones, joints, muscles, tendons,
ligaments, bursae, nerves, and blood vessels.
 The term “Orthopaedic” is derived from Greek words meaning
‘straight child’.
 Orthopaedics originally dealt with the art of correcting deformities in
children.
DIAGNOSIS OF ORTHOPAEDIC DISORDERS

 Depends first upon an accurate determination of all the abnormal

features from
 1. History
 2. Clinical examination
 3. Radiographic examination/ imaging
 4. Special investigations
 Secondly, upon a correct interpretation of the findings.
HISTORY

 Except in the most obvious conditions, a detailed history is always required,

the exact nature of the patient’s complaint being determined.
 The development of symptoms is traced step by step from their earliest
beginning up to the present.
 It is important to take into consideration the patient’s own views on the
cause of the symptoms. They are often correct.
  Pay attention to the following:
 • Relieving and aggravating factors/activities
 • Effect of any previous treatment
 • Presence or absence of symptoms in other parts of the body
 • Whether the general health of patient affected
 • History of previous illnesses
Facts that often have an important
bearing
1. Age
 2. Present occupation
 3. Previous occupation
 4. Hobbies and recreational activities
 5. Previous injuries.
  In cases that seem trivial, inquire tactfully as to why patient
decided to seek advice, and to what extent he is worried by his
disability.
CLINICAL EXAMINATION

The clinical examination should include:

 1. Examination of the part complained of

 2. Investigation of possible sources of referred symptoms
 3. General examination of the body as a whole
Exposure for examination

 The part to be examined should be adequately exposed and in good

light, and when a limb is being examined, the sound limb should
always be exposed for comparison.
Inspection

  The bones – general alignment and position of the parts to detect

any deformity, shortening, or unusual posture.
  The soft tissues – observe soft tissue contours. Compare the two
sides. Note swelling and muscle wasting.
  Color and texture of the skin – look for redness, cyanosis,
pigmentation, shininess and loss of hair.
  Scars or sinuses – if a scar is present, determine from its
appearance whether it was caused by:
 1. Operation (linear scar with suture marks)
 2. Injury (irregular scar), or
 3. Suppuration (broad, adherent, puckered skin).
Palpation

 Four points should be considered:

 1. Skin temperature
 2. The bones – general shape and outline.
 • Feel for thickening, abnormal prominence, and disturbed relationship of the
normal landmarks.
 3. The soft tissues
 • Muscles
 • Joint tissues: thickened synovial membrane; effusion
 • Local swelling: ? Cyst; ? Tumor; General swelling of the part.
 4. Local tenderness.
 • The exact site of any local tenderness should be mapped out and an attempt
made to relate it to a particular structure
Measurements

 Measurement of limb length is often necessary especially in the lower

limbs, where discrepancy between the two sides is important.
 Measurement of limb circumference (compare two sides at the same
site) provides an index of: muscle wasting, soft tissue wasting, and
bony thickening.
 Estimation of fixed deformity
 Fixed deformity exists when a joint cannot be placed in the neutral
(anatomical) position. The degree of fixed deformity at a joint is
determined by bringing the joint as near as it will come to the neutral
(anatomical) position and then measuring the angle by which it falls
short.
Movements

 The following should be sought in the examination of joint movement:

 • What is the range of active movement?
 • Is passive movement greater than active?
 • Is movement painful?
 • Is movement accompanied by crepitation?
 • Is there any spasticity (stiff resistance of free movement)?
Movements

 It is wise always to use the unaffected limb for comparison.

 Limitation of movement in all directions suggests some form of arthritis.
 Selective limitation of movements in some directions with free movement in
others is more suggestive of a mechanical derangement.

 The passive range will exceed the active range only in the following
circumstances: -

 1. When the muscles responsible for the movements are paralyzed.

 2. When the muscles or their tendons are torn, severed or unduly slack.



 Healthcare organisations

 Stability

 The stability of a joint depends partly upon the integrity of its

articulating surfaces and partly upon intact ligaments, and to some
extent upon healthy muscles. When a joint is unstable, there is
abnormal mobility; for instance, lateral mobility in a hinge joint.
Power

 The power of the muscles responsible for each movement of a joint is

determined by instructing the patient to move the joint against the
resistance of the examiner. Compare the two sides.

 Power 0 - no contraction
 Power 1 - a flicker of contraction
 Power 2 - slight power, sufficient to move the joint only with gravity
eliminated.
 Power 3 - power sufficient to move the joint against gravity.
 Power 4 - power to move the joint against gravity plus added resistance.
 Power 5 - normal power.
Sensation

 Test for sensibility to light touch and to pin prick throughout the
affected area.

 In unilateral affection the opposite side should be similarly tested.

 Any blunting or loss of sensibility should be carefully mapped out.

 Identify the nerves affected (dermatomes).

Peripheral circulation

 Examine for the following: -

 1. The color of the skin – normal pink or pale, cyanosed.
 2. The temperature of the skin – cold in impaired arterial supply
 3. The texture of the skin and nails – ischaemia causes loss of hair,
thin & inelastic skin, coarse, thickened, irregular nails
 4. The arterial pulses – lower limb (dorsalis pedis, posterior tibial,
popliteal, femoral)
 5. Capillary return
Reflexes

 Deep reflexes: Determine the integrity of central nervous system or

peripheral nervous system. They are exaggerated in CNS problem
and depressed in PNS problem.
 Superficial reflexes: motor responses to scraping of the skin, e.g.
abdominal reflex; Cremasteric reflex; plantar reflex.
 Tests of function

 Assess how much the disorder affects the part in its fulfillment of
everyday activities. E.g. observe the patient standing, walking,
running, jumping, ascending and descending stairs.
INVESTIGATION OF THE
POSSIBLE SOURCES OF
REFERRED

SYMPTOMS
Think of possible extrinsic disorders with referred symptoms. E.g.:
 1. For shoulder pain, examine the neck (Brachial plexus), thorax,
abdomen (diaphragmatic irritation).
 2. For hip pain, examine the back (spine) and sacro-iliac joints.
 3. Pain in the thigh – examine the spine, abdomen, pelvis, genito-
urinary system, or hip
GENERAL EXAMINATION

 1. Examine the patient as a whole.

 2. Assess the general physical condition and psychological
outlook of the patient.
 3. Do systemic examination.
DIAGNOSTIC IMAGING

 You can carry out the following investigations: -

 1. Radiography
 2. Ultrasound scanning
 3. Computerized tomography (CT) scanning
 4. Magnetic resonance imaging (MRI)
 5. Radioisotope scanning
 6. Positron emission tomography (PET CT)
Radiography

 Plain radiography – X-rays

 At least two projections in planes at right angles to one another –
usually AP & Lateral views
 The films should always include a good length of bone above and
below the site of the injury or lesion, including the adjacent joints.
Contrast radiography

 • Myelography – in which the spinal theca is outlined with an oily non-

absorbable contrast medium (fluid).
 • Radiculography – in which water-soluble absorbable contrast
medium allows visualization of the nerve sleeves, as well as the
spinal theca itself. (Especially used for lumbar spine).
 • Arthrography – outlines the cavity of a joint.
 • Arteriography or angiography- to show the arterial tree.
 • Venography – shows network of veins.
 • Lymphangiography – shows lymphatic network
 • Sinography – defines the course and ramifications of a sinus.
SPECIAL INVESTIGATIONS

 Depend on the condition you are dealing with.

 • Haematological – e.g. haemogram, ESR
 • Serological – e.g. Widal test, V.D.R.L
 • Bacteriological – E.g. Gram stain, Culture and sensitivity
 • Biochemical – upon urine, plasma, cerebrospinal fluid
 • Histological - biopsy
Assignment

  Outline the steps taken in reading and correctly interpreting a plain

radiograph in orthopaedics.
Summary

 Diagnosis of orthopaedic disorders depends:

  First, upon an accurate determination of all the abnormal features
from
 History
 Clinical examination
 Radiographic examination/ imaging
 Special investigations
  Secondly, upon a correct interpretation of the findings.
TREATMENT OF ORTHOPAEDIC DISORDERS

 Orthopedic treatment falls into three categories: -

 1. No treatment – simply reassurance and advice
 2. Non-operative treatment
 3. Operative treatment
NON-OPERATIVE TREATMENT
METHODS

 REST
 • Is one of the mainstays of orthopaedic treatment
 • This may be in the form of bed rest or immobilization of the
diseased part
SUPPORT

 • Rest and support often go together

 • Support can be used to:
 1. Stabilize a joint rendered insecure by muscle paralysis
 2. Prevent the development of deformity
 3. Support can be provided by cast, splint or orthosis
Examples of orthoses include:

 • 1. Spinal braces or corsets

 2. Cervical collars
 3. Wrist supports
 4. Walking calipers
 5. Knee and ankle orthoses, and devices to control foot drop.
Spinal braces(corset).
Spinal braces(corset).
Cervical collars
Cervical collars
Wrist support
Walaking calipers
Ankle orthoses
PHYSIOTHERAPY

 Is very useful in non-operative and post-operative management of

orthopaedic conditions.
 Physiotherapy can be:
 1. Active
 2. Passive
 3. A combination of active and passive
Active interventions

 Exercises and Physical fitness.

 Exercises aim to: Strengthen specific muscles; Stretch soft tissues;
Mobilize joints; and Improve co-ordination of muscles.
 Physical fitness programmes include aerobic exercise with an aim to
improve overall cardiovascular fitness, as well as specific exercises.
 Hydrotherapy is a way of allowing active pain-free movements of all
joints in warm water.
Passive interventions

 Are carried out by the therapist and do not require any active
participation by the patient.
 To preserve full mobility when the patient is unable to move the joint
actively, e.g. when muscles are paralyzed or severed.
 Passive interventions include:
 Manual therapy;
 Soft tissue techniques;
 Traction;
 Electrotherapy;
 and Ultrasound.
LOCAL INJECTIONS

 Indicated in two scenarios:

 1. In joint affections that require intra-articular injection of drugs
 E.g. injection of hydrocortisone or other steroid into the joint in
osteoarthritis or rheumatoid arthritis
 2. In extra-articular lesions ascribed to chronic strain such as tennis
elbow, tendonitis about the shoulder, and certain types of back pain.
DRUGS

 Treatment of Orthopaedic conditions - Drugs

 Categories of drugs used include:
 • Antibacterial agents
 • Analgesics
 • Sedatives
 • Anti-inflammatory drugs
 • Hormone-like drugs
 • Anti-osteoporosis drugs
 • Specific drugs
 • Cytotoxic drugs
Antibacterial agents

 Are used in infective lesions such as: Acute osteomyelitis; acute

pyogenic arthritis; and Tuberculosis.
 Treatment must be started early for best outcomes.

 Analgesics and sedatives

 Analgesics should be used as sparingly as possible
 It is undesirable to prescribe analgesics continuously for prolonged
periods
 Sedatives may be given if needed to promote sleep, but should not
be overprescribed.
Anti-inflammatory drugs

 These are drugs that dampen excessive inflammatory response by

inhibiting the cyclooxygenase enzymes responsible for prostaglandin
formation. Non-steroidal anti-inflammatory drugs are to be preferred.
Many of these drugs also have analgesic action.
 Steroids such as cortisone, prednisolone, and their analogues should
be used with extreme caution due to possible adverse effects.
Hormone-like drugs

 These include:
 i. Corticosteroids
 ii. Sex hormones or analogues used for prevention of osteoporosis in
post-menopausal women, and for the control of certain metastatic
tumours such as hormone-dependent breast and prostatic tumours.
 iii. Biphosphonates – drugs which block the resorption of bone
mineral.
Specific drugs

 • Vitamin C for scurvy

 • Vitamin D for rickets
 • Salicylates for arthritis of rheumatic fever
cytotoxic drugs

 Form the basis of chemotherapy for malignant tumours.

 These anticancer drugs include: Cyclophosphamide, Melphalan,
Vincristine, Doxorubicin, and Methotrexate.
 They have serious side effects and are used only under expert
supervision.
MANIPULATION

 This is the passive movements of joints, bones, or soft tissues carried

out by the surgeon – with or without anaesthesia, and often forcefully
– as a deliberate step in treatment. This method has three main uses:
 i. Manipulation for correction of deformity – e.g. reduction of fractures
and dislocations; correction of deformity from contracted or short soft
tissues e.g. CTEV.
 ii. Manipulation to improve the range of movements at a stiff joint
 iii. Manipulation for relief of chronic pain in or about a joint, especially
in the neck or spine.
RADIOTHERAPY

 Radiotherapy by X-rays or by the gamma rays of radio-active

substances may be used for certain benign conditions or for
malignant disease.
OPERATIVE TREATMENT

 Includes:
 1. Synovectomy
 2. Osteotomy
 3. Arthrodesis
 4. Arthroplasty
Operative treatment.

 5. Bone grafting operations

 6. Tendon transfer operations
 7. Tendon grafting operations
 8. Equalization of leg length
 9. Amputation
Synovectomy

 Is the operation for removal of the inflamed lining of a joint (synovial

membrane), while leaving the capsule intact.
 Useful in early rheumatoid arthritis and in some types of chronic
infective arthritis.
Osteotomy

 Is the operation of cutting bone or creating a surgical fracture

 Indications include: -
 1. Correction of excessive angulation, bowing or rotation of a long bone.
 2. To permit angulation of a bone so as to compensate for mal-alignment at
a joint
 3. To allow for lengthening or shortening of a bone in the lower limb in order
to correct length discrepancy.
 4. To improve stability of the hip by altering the line of weight transmission
(abduction osteotomy)
 5. To improve containment in transient avascular necrosis of the epiphysis
of a long bone
 6. To relieve the pain of an osteoarthritic hip.
Arthrodesis

 This is an operation to fuse a joint

 Indications:
 1. Advanced osteoarthritis or rheumatoid arthritis with disabling pain,
especially when confined to a single joint
 2. Quiescent tuberculous arthritis with destruction of the joint
surfaces, to eliminate risk of recrudescence and to prevent deformity
 3. Instability from muscle paralysis, as after poliomyelitis
 4. For permanent correction of deformity, as in hammer toe.
Arthroplasty

Arthroplasty is the operation for the reconstruction of a new movable joint.

It can be carried out in the following joints: Hip, Knee, Ankle, Shoulder,
Elbow, Hand joints, First metatarso-phalangeal joint.
 Indications of Arthroplasty include:
 1. Advanced osteoarthritis or rheumatoid arthritis with disabling pain,
especially in the hip, knee, ankle, shoulder, elbow, hand and metatarso-
phalangeal joints.
 2. Quiescent destructive tuberculous arthritis especially of the elbow or hip
 3. For the correction of certain types of deformity, especially hallux valgus
 4. Certain ununited fractures of the neck of the femur
Methods of arthroplasty:

 • Excision arthroplasty: Excision of one end or both of the articular

ends so that a gap is created between them, creating a false joint or
pseudoarthrosis.
 • Hemiarthroplasty or half-joint replacement: Only one of the
articulating surfaces is removed and replaced with a prosthesis of
similar shape.
 • Total replacement arthroplasty: Both of the articular ends are
excised and replaced by prosthetic components.
Bone grafting operations

 Types of bone grafts:

 • Autogenous grafts or autografts: are bone grafts obtained from another
part of the patient`s own body
 • Allografts or homogenous grafts or homografts: are bone graft obtained
from another human subject
 • Xenografts or heterogenous grafts or heterografts: are grafts obtained
from animals
 Indications
 • In non-union of fractures to promote union
 • In arthrodesis of joints, either to supplement an intra-articular arthrodesis
or to promote extra-articular fusion
 • To fill a defect or cavity in a bone
Techniques /
Methods(Assignment).
 Strut grafts
 Are obtained from strong cortical bone such as the subcutaneous part
of the tibia. The graft is fixed to the recipient bone by internal fixation
or by inlaying.
 It serves as an internal splint as well as providing a framework for
the growth of new bone.
 Strip grafts
 Sliver or strip grafts are obtained from spongy cancellous bone –
especially from the iliac crest. Commonly used for ununited fractures.
They are laid about the fracture, deep to the periosteum.
 Chip grafts
 Are obtained from cancellous bone; are smaller pieces than sliver
grafts. They are used for non-united fractures; the chips are packed
firmly into or around the recipient bone and held in place by suture of
the soft tissues over them.
 Vascularised grafts
 Require a suitable donor site such as the fibula, rib, or iliac crest.
Anastomosis of nutrient vessels is meticulously done at the new site.
Summary

 In this topic we have learned that;

 Orthopaedic treatment falls into three categories: -
 1. No treatment – simply reassurance and advice
 2. Non-operative treatment
 3. Operative treatment
 We have also discussed the various non-operative methods of
treatment and the operative methods of treatment
PATHOLOGY OF FRACTURES AND
FRACTURE HEALING

 Definition of fracture
 A bone fracture (#) is a break in the continuity of the bone.
 It may be a complete break or an incomplete break of the bone.
 A bone fracture can be the result of:
 • High force impact or stress, or
 • Trivial injury as a result of certain medical conditions that weaken
the bones, where the fracture is then properly termed a pathological
fracture.
Classification of fractures

 Fractures can be classified according to:

 1. Aetiology
 2. Whether open or closed
 3. Fracture pattern
CLASSIFICATION BY AETIOLOGY

 1) Traumatic fractures
 2) Fragility fractures
 3) Fatigue or stress fractures
 4) Pathological fractures
AETIOLOGY

 Traumatic fracture - This is a fracture due to sudden injury or

trauma. e.g. - Fractures caused by a fall, road traffic accident, fight
etc. They occur through bone that was previously free from
disease. May occur by direct violence or by indirect violence.

 Fragility fractures – these are fractures associated with

generalized bone weakness due to osteoporosis. Seen most
commonly in elderly patients
AETIOLOGY

 Fatigue or stress fractures – occur from often-repeated stress

and not from a single violent injury. Commonly occur in athletes
or new military recruits. They occur when the rate of microdamage
exceeds the rate of repair.
 The microdamage accumulates and progresses to a complete fracture
across the full width of the bone. Mostly occur in the metatarsals
(mostly 2nd and 3rd). May also occur in the shaft of fibula, tibia and
neck of femur.
 Pathological fractures – fractures through bone already weakened
by disease. Occur following trivial violence, or even spontaneously.
 Usually occur in conditions that weaken the bones, such as bone
cancer, osteogenesis imperfecta, bone cysts, chronic bone infection.
CLOSED AND OPEN FRACTURES

 All fractures can be broadly described as:

 1.Closed (simple) fractures: Are those in which the skin is intact,

and therefore no communication between the site of fracture and the
exterior of the body.
 2.Open (compound) fractures: There is a wound on the skin
surface that communicates with the fracture.
 May thus expose bone to contamination.
 Open injuries carry a higher risk of infection.

PATTERNS OF FRACTURE

 Fractures can be designated by descriptive terms denoting the shape or pattern

of the fracture.

 The following are the terms in common use:

 1. Transverse fracture: A fracture that is at a right angle to the bone's

long axis.

 2. Oblique fracture: A fracture that is diagonal to a bone's long axis

 3.Spiral fracture: A fracture where at least one part of the bone has
been twisted.

 4.Comminuted fracture: A fracture in which the bone has broken

into several pieces (more than 2).

 5.Compression or crush fracture: usually occurs in the vertebrae,

for example when the front portion of a vertebra in the spine
collapses due to osteoporosis
 6.Greenstick fractures – A greenstick fracture occurs when a bone
bends and cracks, instead of breaking completely into separate
pieces. They are peculiar to children below 10 years. Their bones are
springy and resilient like branches of a young tree (a green stick)
Greenstick fracture

 7.Impacted fractures – the bone fragments are driven so firmly

together that they become interlocked and there is no movement
between them.
 8.Segmental fracture - is a fracture composed of at least two
fracture lines that together isolate a segment of bone, Segmental
fractureusually a portion of the diaphysis of a long bone. It is a
comminuted fracture with middle fragment having the full
circumference intact.

 9.Avulsion fracture: A fracture where a fragment of bone is

separated from the main mass as a result of a tendon or ligament
pulling off a piece of the bone.

 10.Linear fracture: A fracture that is parallel to the bone's long

axis.
HEALING OF FRACTURES

 A fracture begins to heal as soon as the bone is broken.

 Healing proceeds through several stages until the bone is
consolidated.
 Fracture healing, is a proliferative physiological process in which the
body facilitates the repair of a bone fracture.
REPAIR OF TUBULAR BONE


Occurs in five stages:
 1. Stage of haematoma
 2. Stage of subperiosteal and endosteal cellular proliferation
 3. Stage of callus
 4. Stage of consolidation
 5. Remodeling
Stage of haematoma

 • Bleeding torn vessels form a haematoma between and around the

fracture surfaces
 • Haematoma is contained by the periosteum, which may be stripped
up
 • Where the periosteum is torn, the haematoma extravasates into
soft tissues and is contained by muscles, fascia and skin.
 • Deprived of blood supply, about 1or 2 millimeters of bone at the
fracture surfaces dies
Stage of subperiosteal and endosteal cellular
proliferation

 •Within 8 hours of the fracture there is an acute inflammatory

reaction with migration of inflammatory cells and the initiation of
proliferation and differentiation of mesenchymal stem cells.
 •Cells proliferate from the deep surface of the periosteum and the
breeched medullary canal [in the endosteum and marrow tissue].
 •The cells are precursors of osteoblasts, which later lay down the
intercellular substance.
 •The cellular tissue form a collar of active tissue around each
fragment, which grows out towards the other fragment and this
creates a scaffold across the fracture site.
 •The clotted haematoma is gradually absorbed and fine new
capillaries grow into the area.
Stage of callus

 •The differentiating stem cells give rise to osteoblasts and chondroblasts.

fracture callus
 •The osteoblasts lay down an intercellular matrix of collagen and polysaccharide,
which soon becomes impregnated with calcium salts to form the immature bone or
osteoid of fracture callus.
 •Osteoclasts also begin to mop up dead bone.
 •As the immature fibre bone [woven bone] becomes more densely mineralized,
movement at the fracture site decreases progressively and the fracture becomes
rigid.
 •At about 4 weeks after injury the fracture fragments unite and the fracture is said
to be ‘sticky’.
 •The callus may be felt as a hard mass surrounding the fracture.
 •The mass of callus is also visible in radiographs and gives the first indication of
union.
Stage of consolidation

 •With continuing osteoclastic and osteoblastic activity, the woven

bone is transformed into lamellar bone [a more mature bone with a
typical lamellar structure]
 Stage of remodeling
 •Newly formed bone often forms a bulbous collar which surrounds the
bone and obliterates the medullary canal.
 •The mass of callus tends to be large when:
 There is marked periosteal stripping
 The fracture haematoma has been large
 There is marked displacement of the fragments.
 The mass tends to be small when:
 Bone fragments are in exact anatomical apposition
 The fragments are rigidly fixed in close apposition by a metal plate with screws or
by an intramedullary nail.
 •Callus is usually profuse in children because the periosteum is easily stripped
from the bone by extravasated blood, allowing bone to form beneath it.
 •In the months that follow, the bone is gradually strengthened along the lines of
stress, and surplus bone outside the line of stress is slowly removed. The
medullary cavity is gradually reformed, and eventually the bone assumes a shape
as close to normal as possible.
 •In children, remodeling is usually so perfect that eventually the site of the
fracture becomes indistinguishable on radiographs.
 •In adults the site of fracture is usually permanently marked by an area of
thickening or sclerosis.
REPAIR OF CANCELLOUS BONE

 • Healing of cancellous bone follows a different pattern from that of tubular

bone.
 • Because the bone is of uniform spongy texture and has no medullary canal,
there is a relatively much broader area of contact between the fragments,
and the open meshwork of trabeculae allows easier penetration by bone
forming tissue.
 • Union can occur directly between the bone surfaces and it does not have to
take place through the medium of external callus.
 • The first stage of healing is the formation of a haematoma, into which new
blood vessels and proliferating osteogenic cells from the fracture surfaces
penetrate until they meet and fuse with similar tissue growing out from the
opposing fragment.
 • Osteoblasts then lay down the intercellular matrix, which becomes calcified
to form woven bone.
Assignment.

 1. Discuss the rate of union of fractures, outlining factors that

influence the speed of union.
 2. Classify the common causes of pathological fractures.
Summary

 Fractures can be classified according to:

 1. Aetiology
 2. Whether open or closed
 3. Fracture pattern
 Healing of tubular bone occurs in five stages:
 1. Stage of haematoma
 2. Stage of subperiosteal and endosteal cellular proliferation
 3. Stage of callus
 4. Stage of consolidation
 5. Remodeling
PRINCIPLES OF FRACTURE
MANAGEMENT
 Learning objectives
 • Outline the steps in the initial management of a patient with
fracture.
 • Outline the priorities of management of a patient with multiple
injuries
 • Discuss the three fundamental principles of fracture treatment:
Reduction; Immobilization; and Rehabilitation
Initial management

 1.First Aid and Clinical Assessment

 First Aid
 At accident site:
 • Clear the airway
 • Control any external bleeding
 • Cover wounds with clean dressing
Initial management

 • Immobilize fractured limbs

 • Make patient comfortable
 Moving the patient:
 • If fracture of long bone, apply traction while the limb is being
moved
 • If spinal column fracture/dislocation is suspected, avoid flexion of
the spine. In some cases also avoid extension.
 Patient should be lifted bodily (straight) on to a firm surface, and the
neck protected with a cervical collar.
First Aid

 Temporary immobilization of limbs:

 • Bandage the two lower limbs together (sound limb acts as a splint)
 • Bandage arm to chest
 • Apply a sling for forearm
 Control haemorrhage:
 • Apply firm bandage over a pad
 • Application of tourniquet (if profuse pulsatile bleeding despite
pressure). Time of application must be indicated
 • Apply firm manual pressure over the main artery at the root of the
limb
Clinical assessment

 • Follow the priorities of management of a multiple injury patient.

 • Primary survey – ABC
 • Secondary survey
 1. Re-examine ABC
 2. Investigate as per injury
 3. Physical examination of all systems
 4. Drug treatment (analgesics, antibiotics, tetanus toxoid)
Clinical assessment

 Examination of the limb should determine:

 • Whether there is a wound communicating with the fracture
 • Evidence of vascular injury
 • Evidence of nerve injury
 • Evidence of visceral injury
Resuscitation

 Is done during primary survey

 • Airway
 • Breathing
 • Circulation
 Many of the severe trauma patients (multiple fractures with visceral
injury) have problem with circulation. They are usually in shock.
Resuscitation

 1.Correction of shock:
 Immediate replenishment of circulating blood volume
 Infuse electrolyte fluids to establish intravenous infusion: Normal
saline; Ringer’s lactate.
 Plasma expanders (colloids) to replace the lost volume: Dextran – a
high molecular weight polysaccharide; Hemacel – a gelatin solution.
 Transfusion only for severe haemorrhage > 1 liter
1.Correction of shock:

 Priorities of management of multiple injury patient

 Priorities of management of a patient with multiple injuries
 Advanced trauma life support (ATLS)
Steps in the ATLS philosophy:

 1. Primary survey with simultaneous resuscitation – identify and

treat what is killing the patient.
 2. Secondary survey – proceed to identify all other injuries.
 3. Definitive care – develop a definitive management plan.

 On arrival:
 • Take a brief history
 • Do Primary survey – ABC
Airway:

 1. The airway must be evaluated first

 2. Check verbal response. If present, the airway is not immediately at
risk.
 3. Ensure the airway is clear. Clear the mouth and airway with a
large-bore sucker. Inspect for any FBs.
 4. Stabilize the neck to protect the cervical spine.
Breathing:

 1. Make sure the patient is ventilating and if not, assist (Ambu bag,
oxygen)
 2. Give 100% oxygen at high flow
 3. Check for tension pneumothorax
 4. Decompress at once if tension pneumothorax is suspected (needle
in the second intercostal space mid-clavicular line)
Circulation:

 1. Assess consciousness level – compromised cerebral perfusion;

Assess skin colour for pallor; Asses the pulse; BP
 2. Secure an intravenous line
 3. Give I.V. fluids to restore blood volume
 4. Stop obvious bleeding
 5. Blood for GXM, Hb, haematocrit, blood gases
Secondary survey

 Secondary survey involves:

 1. Re-examine ABC
 2. Investigate as per suspected injuries
 • Skull x-ray
 • Chest x-ray
 • Spinal x-ray
 • Pelvic x-ray
Secondary survey

 3. Perform a physical examination of body systems even if you think

they are not injured
 4. Give analgesics
 5. Administer tetanus toxoid in case of open wounds
 6. Give antibiotics in case of open wounds
 7. Splint the fractures
 8. Admit or refer the patient
Definitive care

 There should be as little delay as possible in reaching this stage.

 A definitive management of the injuries identified is carefully planned

and carried out.
Fundamental principles of fracture
treatment

 Are three:
 1. Reduction
 2. Immobilization
 3. Rehabilitation – preservation of function
Reduction

 Reduction is done if necessary. In some cases there is no

displacement, or displacement may be immaterial to the final result.
 Imperfect apposition of the fragments can be accepted, e.g. a loss of
contact of half the diameter in fracture femur.
 Imperfect alignment may not be accepted, e.g. angulation (angular
deformity of more than 20 degrees in fracture femur).
 Fractures involving joint surfaces must be reduced as accurately as
possible. The articular fragments must always be restored as nearly
as possible to normal to lessen the risk of osteoarthritis.
Methods of reduction

 Three methods:
 1. Closed manipulation
 • Manipulative reduction usually under anaesthesia or sedation
and strong analgesia.
 2. Mechanical traction (with or without manipulation)
 • To overcome contraction of large muscles that exert a strong
displacing force.
 3. Operative reduction (open reduction)
Immobilization

 Indications for immobilization:

 • To prevent displacement or angulation of the fragments – in order to
maintain correct alignment
 • To prevent movement that might interfere with union
Immobilization

 • To relieve pain
 Prevention of displacement or angulation:
 • Immobilize to prevent displacement or angulation of the fragments
– in order to maintain correct alignment
 Prevention of movement:
 • Movement is undesirable when it might shear the delicate
capillaries bridging the fracture, e.g. rotation movements.
Immobilization

 Fractures that constantly demand immobilization to ensure their

union are:

1. Fracture of the neck of femur

 2. Fracture of the scaphoid bone

 3. Fracture of the shaft of ulna

Fractures that heal well without
immobilization

 1. Fracture of the ribs

 2. Fracture of the clavicle

 3. Fractures of the scapula

 4. Stable fractures of the pelvic ring

Unnecessary Immobilization

 Immobilization may be unnecessary for certain fractures of the

humerus, femur, metacarpals, metatarsals and phalanges.


• Injured fingers poorly tolerate prolonged immobilization. Leads to
stiffness.
Relief of pain:

 • Relief of pain is an important reason for immobilization

 • The limb is made comfortable

 • It is possible to use the limb without causing movement at the

fracture site, therefore causing no pain.
Methods of immobilization

 Four methods:

 1. Plaster of Paris cast (P.O.P), Dyna cast or other external splint, e.g.
cervical collar, malleable strips of aluminium.

 2. Continuous traction

 3. External fixation
 4. Internal fixation
Immobilization by plaster /cast

 Assignment:
 1. Write down the requirements and procedure of application of
plaster of Paris.
 2. Describe the use of:
 a) Plaster-cutting shears
 b) Powered oscillating plaster saw
 c) Plaster spreader
 3. What complications may follow application of P.O.P, and how do
you prevent/manage them?
Immobilization by sustained
traction
 • Used mainly for fractures that are difficult or impossible to hold in
proper position by plaster or external splint alone. E.g.fractures of
shaft of femur.


• Also used when the fragments are difficult to hold in position
particularly when the fracture is oblique or spiral because the elastic
pull of muscles tends to draw the distal fragment proximally so that it
overlaps the proximal fragment.
Immobilization by sustained
traction
 • The pull of muscles must be balanced by sustained traction upon
the distal fragment, by a weight or other mechanical device.


• Angular deformity is prevented by use of a splint e.g. Thomas’s
splint for femur and Braun’s splint/frame for tibia.
Skeletal traction

 Traction is applied to pins passed through the bone. They allow

substantial loads to be applied accurately to the bone itself. Common
sites for application are:
 1. Upper end of the tibia (tibial tuberosity)
 2. Distal femur
 3. Calcaneum
 4. Olecranon
 5. The skull
 6. Pelvis
 7. Greater trochanter
Types of pin used in skeletal
traction
 Two types of pin are in common use:
 1) Steinmann pin
 • Has a trocar and smooth sides
 • Easy to insert, but it can slip sideways after being in position for
some time
 2) Threaded pins, e.g. Denham pin
 • Have threads which grip the bone and prevent lateral slippage
 • Are harder to insert
Skin traction

 • Is applied by means of adhesive strapping stuck directly onto the

skin.
 • They pull the bone indirectly through the overlying skin and
muscles (soft tissues)
 • The soft tissues can be disrupted if too much weight is applied.
 • The usual upper limit is 5 kg (12 lb)
 • Skin traction is suitable for children and the elderly, and as a
temporary measure in adults until definitive treatment is instituted.
Types of traction

 1. Skeletal or skin traction Hamilton-Russel traction

 2. Fixed or sliding

 3. Fixed traction with a splint e.g. fixed to a Thomas's splint.

Types of traction

 4. Fixed traction using gravity e.g. gallows traction.

 5. Sliding traction uses a system of pulleys and weights. E.g.

Hamilton-Russell traction.

 6. Sliding traction can be balanced or not balanced.

 7. In a balanced traction, one weight applies longitudinal

traction and others are applied to the upper and lower ends of the
limb so that it ‘floats’ in a gravity-free field. Balanced skeletal traction
Complications of traction

 1. Over-traction with resultant: -

 • Circulatory embarrassment
 • Stretched or damaged nerves
 • Non-union or delayed union as fragments are held apart and do
not join
 2. Loss of position
 • Slipped, angulated or overlapped
 3. Pressure sores
 4. Pin track infection
 5. Allergy to adhesive strapping
 Assignment:
 1) Describe the procedure of application of skin traction
 2) State the indications, contraindications, and complications of skin
traction
 3) Describe the procedure of application of skeletal traction for fractures
of the femur
 4) State the indications, contraindications, and complications of skeletal
traction
 5) Name the various traction arrangements (e.g. Russell's traction) and
their indications
 6) Name the various parts of an orthopaedic bed and traction
apparatus.
Immobilization by External Fixation

 • External fixation implies anchorage of the bone fragments to

an external device such as a metal bar through the medium of pins
inserted into the proximal and distal fragments of a long bone
fracture.
 • Threaded pins are inserted into the bone from one side.
 • Two or three pins are inserted into each fragment and the
protruding ends of the pins are clamped to the rigid body of the
fixator, which lies just clear of the skin surface parallel with the
fractured bone.
External Fixation
External Fixation
External Fixation
Indications of External Fixation

 1. Stabilization of severe open fractures

 2. Stabilization of fractures associated with infection or

nonunion

 3. Severely comminuted diaphyseal and peri-articular fractures

 4. Closed fracture with associated severe soft tissue injuries

Indications of External Fixation

 5. Severely comminuted and unstable fractures

 6. Pelvic ring disruptions # with severe soft tissue injury

 7. Arthrodesis

 8. Fractures that are associated with bony deficits

 9. Limb-lengthening procedures

 10. Osteotomies
Immobilization by internal
fixation
 Indications:
 1. To provide early control of limb fractures when conservative
methods would interfere with the management of other severe
injuries, for instance of the head, thorax or abdomen.

2. As a method of choice in certain fractures, to secure immobilization
of the fracture and to allow early mobility of the patient, e.g. in the
elderly patient with trochanteric hip fracture
Immobilization by internal
fixation
 3. When it has been necessary to operate upon a fracture to secure
adequate reduction

4. If it is impossible in a closed fracture to maintain an acceptable
position by splintage alone.
Immobilization by internal
fixation

5. Fractures that cannot be controlled in any other way

6. Patients with fractures in more than one bone

7. Fractures in which the blood supply to the limb is jeopardized and
the vessels must be protected

8. Intra-articular, displaced fractures
Methods of internal fixation

 1) Metal plate held by screws or locking plate (with screws fixed

to the plate by threaded holes)
 2) Intramedullary nail – plain [e.g. K-nail] or interlocking i.e. with
locking screws [e.g. Sign nail] Interlocking nail
 3) Dynamic compression screw-plate [dynamic hip screw] K-nail
 4) Condylar screw-plate
 5) Tension band wiring
 6) Transfixion screws
 7) Kirschner wire fixation
Metals for internal fixation

 • Must be resistant to corrosion in the tissues.

 • A special stainless steel containing chromium, nickel and
molybdenum is widely used.
 • A non-ferrous alloy containing chromium, cobalt and
molybdenum has even better resistance to corrosion in the body and
is used for all types of internal appliance except wire.
 • Titanium and its alloys are also resistant to corrosion and are
used for the manufacture of prostheses and internal fixation devices.
The place of operative fixation

 Operative fixation is accepted as the best routine method of treating

fractures of the neck and trochanteric region of the femur in the
elderly. Intramedullary nailing is used for most fractures of the shaft
of femur or tibia, and many fractures of the upper limb are also now
routinely operated on.
Advantages of internal fixation

 1. Substantial reduction in hospital stay and time away from work


2. Function of the limb, and particularly of the joints, may be restored
earlier

3. By providing rigid fixation of the fracture, complications such as
delayed union and non-union will be reduced.
Rehabilitation

 Rehabilitation is always essential, and should begin as soon as the

fracture is under definitive treatment.

Rehabilitation

 The purpose of rehabilitation is to: -

 Preserve function while the fracture is uniting.

 Restore function to normal when the fracture is united.

 This is achieved by encouraging the patient to help himself by active

use and active exercises. Supervision of a physiotherapist is required.
Summary

 In this topic you have learnt steps in the initial management of a

patient with fracture (First aid); Priorities of management of a patient
with multiple injuries (Primary survey, Secondary survey); and
Fundamental principles of fracture treatment, which are three:
 1) Reduction
 2) Immobilization
 3) Rehabilitation – preservation of function
OPEN FRACTURES

 Definition:
 A fracture is open or compound when there is a wound on the skin
surface leading down to the site of fracture.
 A fracture is classified as open only when a direct communication
exists between the body surface and the fractured bone ends.
Gustilo-Anderson Classification of open
fractures

 Type I:
 Clean wound smaller than 1 cm in diameter, Appears clean, Simple
fracture pattern, No skin crushing.

 Type II:
 A laceration larger than 1 cm but without significant soft tissue
crushing: No flaps, No degloving, No contusion [a bruise]. Simple
fracture pattern
Gustilo-Anderson Classification of
open fractures
Gustilo-Anderson Classification of
open fractures
 Type III:
 High-energy injury with extensive soft tissue damage; or an open
segmental fracture or multifragmentary fracture, or bone loss
irrespective of the size of skin wound; or Severe crush injuries; or
vascular injury requiring repair. Also included are injuries older than 8
hours or severe contamination.
Gustilo-Anderson Classification of
open fractures
 Type III injuries are subdivided into three types:
 Gustilo-Anderson type III

 Type III A: Adequate soft tissue coverage of the fracture despite high
energy trauma or extensive laceration or skin flaps.
 Type III B: Inadequate soft tissue coverage with periosteal stripping.
Soft tissue reconstruction is necessary.
 Type III C: Any open fracture that is associated with vascular injury
that requires repair.
Gustilo-Anderson Classification of
open fractures
Treatment of open fractures

 An open fracture requires urgent attention.

 The sooner the wound can be dealt with, the smaller is the risk of
infection arising from contaminating organisms.
 Initial management at the emergency department includes carrying
out a primary survey – ABC: -
 1. AIRWAY: Ensure airway is clear
 2. BREATHING: Make sure the patient is ventilating and if not
assist (Ambu bag, oxygen)
 3. CIRCULATION:
Treatment of open fractures

 • Assess for bleeding – inspect, pulse, BP

 • Start an IV line
 • Give IV fluids to restore volume
 • Stop obvious bleeding
 • Blood for grouping and cross-match, Hb, haematocrit, blood
gases.
Principles of treatment

 1) Clean the wound by performing a thorough surgical

toilet.
 • Remove all dead and devitalized tissue
 • Remove all extraneous material
 • Aim at leaving healthy, well-vascularized tissues that are able
to fight infection from any remaining contaminating organisms.
 2) The wound should not be subjected to repeated
examination, but should be covered with sterile dressing.
 3) Avoid immediate skin closure.
Technique of operation for major
wounds
 1. Enlarge the skin wound to display clearly the extent of the
underlying damage
 2. Flush the wound with copious quantities of water or saline to
remove all contaminating dirt.
 3. Pick out with forceps any foreign matter e.g. shreds (pieces)
of clothing.
Technique of operation for major
wounds
 4. Excise any tissues that are obviously dead

 5. Remove dead or devascularized muscle in order to reduce the

risk of gas gangrene.

 6. Remove bone fragments that are small and completely

detached.

 7. Large bone fragments, which usually retain some soft tissue

attachments, should be preserved.
Technique of operation for major
wounds
 8. The bone ends must be inspected.

 9. When debriding bone, the fracture edges are curetted and all
dirt and non-viable bone are removed.

 10. Damage to major blood vessels is dealt with by:

 • Ligation
 • Suture
 • Or vein grafting
Technique of operation for major
wounds
 11. The ends of severed nerve trunks may be tucked lightly
together with one or two sutures to facilitate later definitive repair.

 12. Tourniquets should be avoided when possible to prevent

additional ischemic injury to the soft tissues.

 13. Necrotic tissue is removed and only viable tissue is left

behind. The exception is skin, where none is removed unless
obviously necrotic.
Technique of operation for major
wounds
 14. The quality of the muscle tissue is assessed using the classic
4 C’s:
 • Color (red or brown)
 • Consistency (how does the muscle feel)
 • Capillary Circulation (does it bleed?)
 • Contractility (responds to pinch or electro-cautery)
Skin closure

 The wound should be left unsutured after surgical toilet and dressed
with sterile covering.

 Delayed closure should be done as soon as infection has been

aborted or overcome (delayed primary suture).


Methods of skin closure

 Direct suture of the skin edges if feasible, depending upon the

amount of skin destroyed and lost in the injury.
 If the skin loss is negligible and the skin edges can be brought
together without tension, direct suture should be done.
 A free split-skin graft is used if the skin edges will not come together
easily (full-thickness skin graft).
 Soft-tissue flaps can also be done.
Treatment of the fracture

 Once the wound has been dealt with, the fracture itself should be
treated following the general principles of managing closed fractures.
 There should be greater reluctance to resort to operative methods of
fixation, due to increased risk of infection.
 If the fracture is unstable and unsuitable for treatment by traction or
by simple splintage, external fixation should be done. This provides
temporary stabilization and minimizes additional soft-tissue injury.
This fixation facilitates access to the wound for inspection between
debridements.
 Once the wound has healed, the fracture can be immobilized in
plaster for the remaining duration of treatment.
Other treatment

 1. Antibiotics:
 • A course of treatment with a broad-spectrum antibiotic, such as a
third generation cephalosporin, should be begun immediately and
continued until the danger of infection is past.

 • Antibiotics should be given intravenously.

Other treatment

 2. Prophylaxis against tetanus:

 • Tetanus toxoid should be given and repeated 6 weeks later or a

booster should be given if the patient was already immunized
previously.

 3. Analgesics

 4. Monitor vital signs

 The end!
Summary

 In this topic you have learnt the definition of open fracture, Gustilo-
Anderson Classification of open fractures and the principles of
treatment of open fractures, including:
 Primary survey
 Wound management
 Fracture management
 Prevention of infection/tetanus
COMPLICATIONS OF FRACTURES

 1. Immediate complications - occurs at the time of the fracture.

 2. Early complications - occurring in the initial few days after the
fracture.
 3. Late complications - occurring a long time after the fracture.
Immediate complications

 Systemic
 • Hypovolaemic shock due to haemorrhage
 Local
 • Injury to major blood vessels
 • Injury to nerves
 • Injury to muscles and tendons
 • Injury to joints
 • Injury to viscera
Early complications

 Systemic
 • Fat embolism syndrome
 • Deep vein thrombosis
 • Disseminated intravascular coagulation [DIC]
 • Septicemia (in open fracture)
 • ARDS - Adult respiratory distress syndrome [shock lung or wet lung]
 Local
 • Infection
 • Compartment syndrome
Late complications

 Imperfect union of the fracture

 • Delayed union

 • Non union

 • Mal union

 • Cross union
Others

 • Avascular necrosis

 • Shortening

 • Joint stiffness
Others

 • Sudeck's dystrophy

 • Osteomyelitis

 • Ischaemic contracture

 • Myositis ossificans

 • Osteoarthritis
Complications of fractures can also be
classified as follows:

 Due to associated injury

 • Injury to major blood vessels
 • Injury to nerves
 • Injury to viscera
 • Injury to tendons
 • Injuries and post-traumatic affections of joints
 • Fat embolism
 • Compartment syndrome
Related to the # itself

 • Infection

 • Delayed union

 • Non-union

 • Avascular necrosis

 • Mal-union

 • Shortening
Infection

 • Is common in open fractures contaminated by organisms carried in

from outside.

 • Could also follow operative treatment of a closed fracture

 • Very rarely occurs in some closed fractures due to bacteraemia

 • Infection often leads to osteomyelitis

 • The infection of bone tends to become chronic.

Treatment:

 • Acute infection is treated by:

 Establishing free drainage

 Antibacterial medication – choice depends on sensitivity of the

organisms.

 • Chronic infection:
 Sequestrectomy and saucerization and chiseling away bone with
small pus containing cavities
Mal-union

 • Refers to a fractured bone that has united soundly but in the wrong
position (imperfect position).
 • Results from improper or imperfect reduction
 • Commonly presents as angulation, rotation, loss of end-to-end
apposition, or overlap and consequent shortening.
 • Treatment of clinically significant mal-union is by dividing the bone,
correcting the deformity, and fixing the fragments by the
appropriate means.
Delayed union

 • A fracture with delayed union takes longer than expected to unite,

but eventually does so.
 • Union is usually deemed to be delayed if the fracture is still mobile
3 or 4 months after the injury.
 • In delayed union, there is nothing in the condition of the bones to
indicate that union will fail altogether.
Non-union

 • Healing process fails

 • Bone ends do not unite and remain separate
 • The bone ends at the site of the fracture become dense and
rounded.
 • The fracture line becomes increasingly clear-cut.
 • Two types of non-union are seen:
 1. Hypertrophic non-union
 2. Atrophic non-union
Hypertrophic non-union:

 • Occurs due to excessive movement at the fracture site, with

abundant callus formation but failure to unite due to
instability.
 • Characterized by a massive cuff of bone around the ends of the
fractures that looks like an elephant’s foot.
 • These fractures are trying desperately to heal.
 • Healing can be enhanced by realigning the limb and preventing
movement between the bone ends.
 • Prevention of movement can be done by rigid internal fixation
Atrophic non-union:

 • The fracture gap is filled by fibrous tissue and the bone fragments
remain mobile.
 • Shows rounding of the bone ends, sometimes so marked that the
tips of the bone ends resemble pencils, and the medullary cavity
may be closed.
 • This is indicative of a poor blood supply to the bone ends.
 • A pseudoarthrosis forms in some patients.
 • Treatment aims to ‘kick start’ osteogenesis by bone grafting with
fresh cancellous bone or marrow.
Causes of non-union include:

 1. Infection of the bone

 2. Incomplete reduction
 3. Excessive shearing movements between the fragments
 4. Interposition of soft tissues between the fragments
 5. Loss of the fracture haematoma in an open fracture
 6. Dissolution of fracture haematoma by synovial fluid (#s within joints)
 7. Destruction of bone as by a tumour
 Treatment:
 • Bone grafting operation
 • Joint replacement operation e.g. Austin-Moore prosthesis in fracture of
the neck of femur
Avascular necrosis

 This is death of bone from a deficient blood supply.

 It occurs when the blood supply to a bone or part of a bone is
interrupted by injury.
 It usually occurs as a complication of a fracture near the articular end
of a bone, especially where the terminal fragment is devoid of
vascular soft tissue attachments and depends for its nutrition almost
entirely upon the intra-osseous vessels which may be torn by the
injury. It often leads to non-union and osteoarthritis. The avascular
bone gradually loses its rigid trabecular structure and becomes
granular or gritty. The bone crumbles easily and may eventually
collapse from pressure imposed by muscle tone or body weight.
Sites of avascular necrosis:

 • Head of the femur after # neck of femur or hip dislocation

• Proximal half of the scaphoid bone after a fracture through
the waist of the scaphoid
• Body of the talus after a fracture through the neck of the
talus
• Lunate bone may undergo avascular necrosis after its
dislocation.
Diagnosis:

 • May be recognized from radiographs about 1-3 months after injury


• The avascular fragment appears denser due to its not taking part in
the osteoporosis of disuse affecting surrounding bones.

• Fragment may have reduced height, with a shrunken crumbled
appearance.
Treatment:

 • Early operation to prevent joint disorganization


• Promote revascularization by drilling the avascular fragment, with
or without bone grafting.

• Excision of the avascular fragment and replacing it with a
prosthesis, (arthroplasty) or perform arthrodesis.
Post-traumatic ossification

 Is a rare cause of joint stiffness after fracture or dislocation. It is

Sometimes called myositis ossificans. It occurs in severe injury to a joint,
especially when the capsule and periosteum have been stripped from
the bones by violent displacement of the fragments. Blood collects under
the stripped soft tissues, forming a large haematoma about the joint.
Instead of being absorbed, the haematoma is invaded by osteoblasts
and becomes ossified. This leads to restriction of joint movement. It is
encountered most commonly in the elbow after fracture-dislocation. It
also occurs in the hip after dislocation. There is greater risk of
occurrence in children than in adults because the periosteum is only
loosely
 Treatment
 1) Gentle active exercises
2) Excise a mass of bone that is blocking movement.
Osteoarthritis

 • Occurs due to roughening or irregularity of joint surface

 • Is likely to develop sooner or later after any displaced fracture

which involves an articular surface


Osteoarthritis

 • Even a slight step between the fragments may lead to serious

subsequent disability from arthritis, esp. in a weight bearing joint.

 • Avascular necrosis is also an important cause of

osteoarthritis.

 • There is risk of osteoarthritis if fracture fragments unite with

angular deformity because mal-alignment of joint surfaces
causes excessive stress at one part of the joint and accelerates wear-
and-tear changes.
Compartment syndrome

 This is a rise in hydrostatic pressure within a fascial compartment

leading to compromised circulation within the compartment, with
resultant tissue ischaemia and eventually, necrosis.
Compartment syndrome

 Pathophysiology:
 Muscles are contained within fascial compartments. If swelling occurs within a
compartment as a consequence of injury, the fascia resists the swelling, and pressure
within the compartment rises greatly. Increased pressure occludes the veins and
small arteries supplying the muscles causing ischaemia. Muscle ischaemia in turn
promotes further swelling worsening the situation. Within a few hours, irreversible
changes may occur:
 The muscles may become necrotic
 The nerves within the affected compartment lose their conductivity because of
ischaemia
 The muscles are eventually replaced by fibrous tissue, which contracts causing
Volkmann’s ischaemic contracture.
 Volkmann’s ischaemic contracture is seen most often in the flexor muscles of the
forearm and lower leg.
Compartment syndrome

 Clinical features
 • Severe pain in the limb
• Pain worsened by attempted passive extension of the digits
• Pallor of the limb
• Coldness of the limb
• Pulses may be absent if the relevant artery is contained within the
affected compartment.
Compartment syndrome

C/F
 A lack of pulse rarely occurs in patients, as pressures that cause
compartment syndrome are often well below arterial pressures.
Therefore, in compartment syndrome the peripheral arterial pulses
may still be present, and this could cause confusion as to the true
diagnosis.
 • Tense and swollen shiny skin.
• Congestion of the digits with prolonged capillary refill time.
• Paraesthesia (altered sensation e.g., "pins & needles") in the
cutaneous nerves of the affected compartment.
• Paralysis of the limb is usually a late finding.
Compartment syndrome

 Treatment
 • Immediate operation to decompress the whole length of the
affected compartment or compartments by fasciotomy.
• The fascial compartments and the skin must be divided so that the
muscle can swell.
• The wound is left open until swelling has subsided, after which it
may be closed or grafted.
Compartments

 Forearm
 1) Ventral (flexor) compartment
• Includes the median and ulnar nerves, and the radial and ulnar
arteries.

 2) Dorsal (extensor) compartment

• Is less often damaged than the ventral
 • It includes the posterior interosseous nerve but no major vessels.
 • Consequences are less serious.
Compartments

 Lower limb

1) Anterior tibial compartment
• Contains the anterior tibial artery and deep peroneal nerve

 2) Superficial posterior compartment

• Composed of gastrocnemius and soleus only
 • Has no important vessels or nerves
 3) Deep posterior compartment
• Contains the posterior tibial vessels and nerves and the peroneal artery
 • Consequences are serious
 4) Lateral (peroneal) compartment
• Contains the superficial peroneal nerve, but it is seldom affected by compression.
Fat Embolism Syndrome

 Fat embolism syndrome

  Is one of the most serious complications of fractures
 The essential feature is occlusion of small blood vessels by fat
globules.
 Pathology
 Fat embolism syndrome mainly affects the lungs and brain. Occlusion
of blood vessels leads to oedema and haemorrhages in the alveoli of
the lungs. Transfer of oxygen from the alveoli to arterioles is thus
impaired. This leads to hypoxaemia, which may be severe. In the
brain there may be multiple petechial haemorrhages. Petechial
haemorrhages occur also in other organs and in the skin.
Fat Embolism Syndrome

 Clinical features
 1. Occurs mainly after severe fractures in the lower limbs particularly
those of the femur and tibia.

2. The onset is usually within two days of the injury

3. There is a symptom-free period between injury and onset. This
distinguishes fat embolism from cerebral contusion.

4. Breathlessness
Fat Embolism Syndrome

 Clinical features

 5. Cerebral disturbance

6. Marked restlessness

7. Confusion

8. Drowsiness or coma
Fat Embolism Syndrome

 Clinical features

 9. Cerebral symptoms may be caused partly by petechial haemorrhages in the brain, but in large
measure they are probably secondary to hypoxia from occlusion of small blood vessels in the
lungs.

10. Tachypnoea

11. Dyspnoea

12. Petechial rash

 • On the front of the neck

 • On the anterior axillary folds or chest
 • In the conjunctiva
 The finding of such a rash strongly supports a diagnosis of fat embolism syndrome.
Diagnosis

 1) Characteristic clinical features


2) Arterial blood gas analysis may show reduction of the partial pressure of
oxygen in the blood well below 100mmHg and often below the critical
level of 60mmHg at which respiratory failure is likely.

3) Chest radiographs show patchy consolidation

4) Platelet count is low

5) Serum lipase is low

6) Fat globules may be present in the urine
Treatment

 Fat embolism is spontaneously reversible if the patient can be tided

over the dangerous period of hypoxia.
 • This may be achieved by administration of 100% oxygen with
positive pressure ventilation if necessary. Control oxygen
requirement by repeated blood gas analysis

• Patient needs to be managed in the intensive care unit.
• The administration of methylprednisolone in patients with severe
multiple injuries may help to prevent and correct the adverse
effects of fat embolism by maintaining blood oxygen tension and
stabilizing the free fatty acids.
• Heparin or Dextran 40 may also be administered intravenously to
improve capillary flow.
Reflex sympathetic dystrophy

 Also known as: Sudeck’s atrophy, Sudeck’s post-traumatic

osteodystrophy, Post-traumatic painful osteoporosis, Complex
regional pain syndrome.
 • It is characterized by pain, swelling and marked joint stiffness in the
hand or foot of the injured limb.
• The cause and exact nature of the condition are unknown.
• Probably due to a disturbance of centrally mediated autonomic
regulation with consequent increased stimulation of
sympathetic and motor efferent fibres.
Reflex sympathetic dystrophy-
Assignment.
 Clinical features
 • Symptoms are noticed about 2 months after the injury, or when the
plaster is removed.
• The function of the limb is not regained as it should be with active use and
exercises.
• Instead, the patient complains of severe pain in the affected hand or foot
when attempting to use it.
• On examination:
1) The limb is swollen and may be hyperaemic.
2) The skin creases are obliterated, giving the surface a glossy appearance
3) The nails and hair of the hand or foot are atrophic.
4) The palmar aponeurosis may be thickened
5) Joint movements are severely impaired, esp. the metacarpophalangeal
and interphalangeal joints (‘frozen hand’)
6) Radiographs show spotty osteoporosis, often of severe degree.
Reflex sympathetic dystrophy

 Treatment
 • Most cases respond slowly but surely to efficient conservative
treatment.
• Mainstay of treatment is active exercise, with active use of the limb
so far as the pain will allow.
• Periods of elevation and local heat (warm baths)
• Adequate recovery is usually gained in 2-4 months.
Intra-articular and peri-articular
adhesions

 • Joint stiffness after adhesions is common after fractures, esp. those

that are near a joint.
• The knee, shoulder, elbow and finger joints stiffen easily and often
suffer permanent impairment.
• The hip and wrist usually regain their full mobility without difficulty.
• Adhesions occur chiefly after a fracture that has involved the
articular surface of a bone. Blood escapes into the joint
(haemarthrosis) and may leave residual strands of fibrin which later
become organized into fibrous adhesions between opposing
folds of synovial membrane.
Intra-articular and peri-articular
adhesions

 • Peri-articular changes are a more frequent cause of joint stiffness

than intra-articular adhesions. Due to the injury and possibly
prolonged immobilization, oedema fluid collects in the tissues,
binding together the connective tissue fibers. This
leads to loss of resilience of the peri-articular tissues such as joint
capsule and ligaments, and also impairs the free gliding of
muscle fibres one upon another.
• Direct adhesion of muscle to the underlying bone at the site of
fracture is another cause of stiffness
Intra-articular and peri-articular
adhesions
 Treatment
 1) Active exercises preferably under supervision of physiotherapist
2) Manipulation:

 • Manipulation under anaesthesia may be considered if active

exercises and use are not achieving steady improvement.
 • Manipulation is more likely to be successful in overcoming stiffness
from intra-articular adhesions.
 3) Operation to release the adhesions
Summary

 In this topic you have learnt the classification of various

complications of fractures -
 • Immediate – local and systemic
 • Early - Local and systemic
 • Late - due to imperfect union of fracture or other causes
 • Complications related to the fracture itself
 • Complications due to associated injury
 You have also learnt the management of the complications.
SPECIAL FEATURES OF FRACTURES IN
CHILDREN

 Injuries involving the growth plate

 • Also known as epiphyseal injuries
 • Each end of the long bones has a cartilaginous growth plate.
 • Most growth occurs away from the elbow and towards the
knee.
 • The growth plate is a potentially weak point in the bone and
is commonly injured in children.
 • Epiphyseal injuries can be classified radiologically into five
types as described by Salter and Harris.
 • Designated as Salter-Harris classification.
Salter-Harris classification

 Salter-Harris classification
 • Type I injury: complete separation of epiphysis at the growth
plate without damage to the metaphysis or epiphysis.
 • Type II injury: the most common type, with a characteristic
triangular fragment of the metaphysis attached to the
displaced epiphysis.
 • Type III injury: involves the articular surface with separation of
an epiphyseal fragment.
 • Type IV injury: fracture of the articular surface with extension
across the growth plate into the metaphysis.
 • Type V injury: compression fracture involving part or all of the
growth plate.
Salter-Harris classification
Special features of fractures in
children
 Bone resilience
 Bones in children are more resilient and springy, withstanding greater
deflection without fracture. This explains the predominance of
incomplete fractures of the greenstick type in children.
 Periosteum
 The periosteum in children’s bones is attached only loosely to the
diaphysis and is therefore easily stripped from the bone over a
considerable part of its length by blood collecting beneath it. This
leads to abundance of callus following injury, even with little
displacement of the fragments.
Special features of fractures in
children
 Site of fracture
 Certain fractures that are common in adults are uncommon in
children; e.g. Fractures of: Scaphoid bone, Neck of femur, Trochanteric
region of femur. Some fractures are quite common in childhood: -
Supracondylar fractures of humerus, Fractures of the capitulum of the
humerus
 Healing
 Healing of childhood fractures is usually rapid, the younger the child
the more rapid the healing. In infancy a fracture may be soundly
united in 2 or 3 weeks; in later childhood the average time required
for union gradually increases. Remodeling is very active and
complete in early childhood; so much so that all evidence of a past
fracture may be obliterated within a matter of months.
Special features of fractures in
children
 Effect on growth
 After a fracture of a long bone in a child, growth is often accelerated for a
time, perhaps from hyperaemia of the neighbouring epiphyseal cartilage.
Growth may be seriously disturbed if the growth plate is damaged. If the
whole area of the growth plate is fused, all growth ceases at that site.
 The degree of consequent shortening will depend on the age at which
premature fusion occurred; the younger the patient at the time of fusion,
the greater the eventual shortening.
 If premature fusion occurs in only a part of the epiphyseal plate, further
growth will be prevented at that point but will continue in the undamaged
part of the plate, leading to angulation deformity. Angulation will also occur
if there is premature arrest in one bone of a pair, as in the forearm or leg.
 The end.
Summary

 In this topic you have learnt some of the special features of fractures
in children:
 1) Salter-Harris classification of epiphyseal injuries
 2) Bone resilience
 3) Periosteum in children
 4) Rate of healing
 5) Effects of fractures on growth
JOINT INJURIES

 A Joint injury is dysfunction of a joint as a result of an injury, following

either acute trauma or chronic overuse.
 A joint injury can involve damage to the bones, ligaments or other
tissues of the joint.
 The larger limb joints tend to be the most utilized and are hence more
prone to injuries.
 Severity of symptoms varies depending on the type and location of
injury and often the primary symptom is pain.
Symptoms of joint injury

 1. Joint pain
 2. Joint swelling
 3. Joint redness Normal parts of a joint (knee)
 4. Joint discoloration
 5. Inability to move joint
 6. Movement problems
 7. Bruising around joint
Symptoms of joint injury

 8. Broken bone in joint

 9. Deformed joint
 10. Joint tenderness
 11. Reduced range of joint motion
 12. Joint weakness
 13. Joint numbness
 14. Joint warmth
JOINT INJURIES
common joint injuries

 A joint injury can be:

 1. A sprain of the joint
 2. A strain of the ligaments
 3. A rupture of the ligaments
 4. A subluxation of the joint
 5. A dislocation of the joint
Sprain/ Strain / Rupture

 A sprain is any painful wrenching (twisting or pulling) movement of a

joint that does not cause tearing of the capsule or ligaments.
A strain is a physical effect of tensile stress associated with stretching
of the ligaments, which involves tearing of some fibers.
If the stretching or twisting force is severe enough, the ligament may
be strained to the point of complete rupture.
Strained ligament

 • Only some of the fibers in the ligament are torn and the joint
remains stable.
• The injury occurs when a joint is momentarily twisted or bent into
an abnormal position.
• The joint is painful and swollen and the tissues may be bruised.
• Tenderness is localized to the injured ligament and tensing the
tissues on that side causes a sharp increase in pain.
Treatment of a strained
ligament
 1. The joint should be firmly strapped and rested until the pain
subsides.
2. Ice packs can be applied locally
3. Non-steroidal anti-inflammatory medication
4. Thereafter active movements are encouraged.
5. Muscle strengthening exercises are carried out.
Ruptured ligament

 The ligament is completely torn and the joint is unstable. Sometimes

avulsion of the bone to which the ligament is attached occurs if the
ligament holds and fails to rupture. Treatment is easier in the case of
avulsion because the bone fragment can be securely reattached.
 The mechanism of injury is a sudden forceful twist or bending of the
joint into an abnormal position. The patient might hear a snap sound
during the injury.
 Rupture most likely affects joints that are insecure by virtue of their
shape or their being least well protected by the surrounding muscles.
They include: the knee; the ankle; and finger joints.
Clinical features

 1) Severe pain
 2) Bleeding under the skin (ecchymosis)
 3) Swollen joint, probably due to a haemarthrosis
 4) Very tender joint, patient does not want the joint to be
disturbed
 5) Examination under anaesthesia by stressing the joint
demonstrates joint instability. This distinguishes the lesion from a
strain.
 6) X-ray may show a detached flake of bone in the case of
avulsion.
Treatment of Ruptured ligament

 Torn ligaments heal by fibrous scarring.

 1. Non-operative treatment is encouraged in the first instance.

 •The joint is splinted for 1-2 weeks and local measures taken to reduce
swelling [elevation, cold compress]
 •Thereafter the splint is replaced with a functional brace that allows joint
movement but prevents repeat injury to the ligament.
 •Physiotherapy – muscle strengthening exercises.
 2. In the case of an avulsion of bone with the ligament, reattachment
of the ligament is indicated if the piece of bone is large enough.
Dislocation and Subluxation

 • Dislocation means that the joint surfaces are completely

displaced and are no longer in contact.
 • Subluxation implies a lesser degree of displacement, such
that the articular surfaces are still partly apposed.
Clinical features

 1. Severe joint pain

 2. Patient avoids moving the joint
 3. The shape of the joint is abnormal Dislocated finger
 4. Bony landmarks may be displaced
 5. The limb is held in a characteristic position depending on the
joint affected
 6. Movement is painful and restricted
Investigations.

 X-ray findings
 Radiographs will clinch the diagnosis and will also show if there is any associated
bony injury (fracture-dislocation)

 Apprehension test
 If the dislocation is reduced by the time the patient is seen, the joint can be tested
by stressing it as if almost to reproduce the suspected dislocation: the patient
develops a sense of impending disaster and violently resists further manipulation.

 Recurrent dislocation
 If the ligaments and joint margins are damaged, repeated dislocation may occur.
This is termed recurrent dislocation. This is especially common in the shoulder and
the patella-femoral joint.
Treatment of dislocation/subluxation

 1. The dislocation must be reduced as soon as possible by

manipulation. Posterior dislocation of the shoulder: before and
after reduction
 2. A general anaesthetic is usually required or an opioid
analgesic [e.g. pethidine or morphine]
 3. A muscle relaxant may also be required [e.g. diazepam]
 4. The joint is then rested or immobilized until soft tissue
swelling reduces – usually after 2 weeks.
 5. Physiotherapy
Summary

 In this topic you have learnt about common joint injuries, their clinical
presentation and their management.
 1) A sprain of the joint
 2) A strain of the ligaments
 3) A rupture of the ligaments
 4) A subluxation of the joint
 5) A dislocation of the joint
Complications of
dislocation/subluxation
 1) Vascular injury
 2) Nerve injury
 3) Avascular necrosis of bone
 4) Heterotopic ossification (post-traumatic ossification)
 5) Joint stiffness
 6) Secondary osteoarthritis
THE END!

 THE END!