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    Add as Friend Basics of fracture management

    by: Dr. Md Nazrul

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    1 : WELCOME To Department Of Orthopedics & Traumatology. Shaheed SuHrawardy Medical College Hospital, Dhaka-1207, Bangladesh.
    2 : CME on Basic of Fracture Management Dr. Md Nazrul Islam Resident Surgeon, Dr. Nabarun & Dr. Suhash, Dept. Of Orthopaedics & Traumatology Saheed Surahwardy Medical College Hospital, Dhaka-1207, Bangladesh.
    3 : Definitions Fracture A break in the structural continuity of bone (but we have to remember that there is always some degree of soft tissue injury with a fracture)
    4 : Goals of fracture treatment Prevent fracture and soft tissue complications Get fracture to heal and in satisfactory position for optimal functional recovery Intra-articular fracture needs accurate reduction & rigid fixation but non articular fracture of bone require anatomical reduction & stable fixation. Rehabilitate as early as possible by active & passive exercises. Restore patient to optimal functional state
    5 : How fracture happen A single traumatic incident; Repetitive stress; Abnormal weakening of the bone (pathological fracture)
    6 : How fracture happen.. Twisting causes a spiral fracture; Compression causes a short oblique fracture; Bending results in fracture with a triangular 'butter-fly‘ fragment; Tension tends to break the bone transversely;
    7 : Types Of Fracture (Anatomical over view)
    8 : Types of Fracture…cont. Open fracture : When the bony fragments are exposed to external environment by means of wound Closed fracture : The fracture fragments are not exposed to outside
    9 : Types Of Injury High energy Low energy
    10 : Open (compound) fractures Gustilo classification Type 1 – Low energy, wound <1cm (usually penetrating injury by bony fragments from inside ) Type 2 – Wound >1cm with moderate soft tissue damage Type 3 – High energy wound >1cm with extensive soft tissue damage Type 3A – Adequate soft tissue cover Type 3B – extensive soft tissue injury with external or internal degloving injury which needs flap coverage. Type 3C – any open fracture associated with neuro-vascular injury
    11 : Complications of fractures General complications Shock ARDS Fat embolism Head, chest, abdomen and pelvic injuries Crush syndrome Tetanus Gas gangrene Infections – UTI, Chest DVT/PE Bed sores Depression/PTSD
    12 : Complications of fractures Early Visceral injury Vascular injury Compartment syndrome (later Volkmann conctracture) Nerve injury Haemarthrosis Infection Late Delayed union Non-union Mal-union Tendon rupture Myositis ossificans Osteonecrosis Algodystrophy Osteoarthritis and joint stiffness
    13 : Management of the injured patient Don’t treat the X-rays of the fracture, but treat the patient Life saving measures Diagnose and treat life threatening injuries (head injuries, Chest & abdominal injuries) Emergency orthopaedic involvement Life saving Complication saving Emergency orthopaedic management (day 1) Monitoring of fracture (days to weeks) Rehabilitation and treatment of complications (weeks to months)
    14 : Life saving measures A= Airway and cervical spine immobilisation B = Breathing C = Circulation (treatment and diagnosis of cause) D = Disability (head injury) E = Exposure (musculo-skeletal injury)
    15 : Treatment principle of fracture 1) Reduction 2) Maintain reduction (+ hold until union) 3) Rehabilitate – restore function by movement of the joint & patient itself. 4) Prevent or treat complications
    16 : Open (compound) fractures High risk of infection Can be associated with gross soft tissue damage, severe haemorrhage or vascular injury
    17 : Open (compound) fractures - management While contacting orthopaedic team for definitive surgical treatment Irrigate wound with N.saline, if not available with tap water. Cover wound with sterile moist dressing. Immobilise limb preferable with external fixator if not possible , by pos. cast(including joint above & below) Remove obvious contaminants with meticulous effort Take photos IV antibiotics (e.g. cefuroxime +/- metronidazole or gentamicin) Tetanus prophylaxis. Check distal neurovascular status Re-assess
    18 : Reduction If necessary, what reduction technique? 1) Closed reduction Need anaesthesia/sedation, analgesia, x-ray facilities, equipment, knowledge Used for minimally displaced fractures and most fractures of children Distal part of limb pulled in line of bone Alignment adjusted in each plane 2) Open reduction Above + theatre staff + additional equipment Risks
    19 : Maintain reduction Necessary? 1) Relieve pain 2) Prevent mal-union – nature heals the fracture, we keep it in a good position 3) Minimise non-union – maintenance of reduction should be continuous
    20 : Maintain reduction How? 1) External method POP (+ equivalents), traction, external fixator 2) Internal method Wires, pins, plates, nails, screws
    21 : Maintain reduction – external method 1) POP Mould with palms Adv – cheap,easy to use, convenient, can be moulded Disadv – susceptibility to damage (disintegrates when wet), up to 48hrs to dry , difficulty to care of open wound
    22 : Maintain reduction – external method 2) Resin cast Adv – lighter and stronger, more resistant to damage, sets in 5-10mins, max strength in 30mins Disadvantage – cost, more difficult to apply/remove, more rigid with greater risk of complications eg. swelling and pressure necrosis
    23 : Maintain reduction – external method 3) Surface traction Temporary measure when operative fixation not available for awhile Skin can be injured if applied for long periods of time Neuro-vascular status should be checked during surface traction period
    24 : Maintain reduction – external method 4) Skeletal traction Requires invasive procedure for longer term traction requiring heavier weights Complications associated with pin insertion eg. infection
    25 : Maintain reduction – external method 5) External fixator Indications Fractures associated with soft tissue injury Fracture associated with N/V damage Severely comminuted and unstable fracture Unstable pelvic fracture Infected fracture For skin graft & flap coverage Complications Pin track infection Delayed union
    26 : Maintain reduction – internal method Advantages Restoration of absolute anatomical state Shorter hospital stay Enables individuals to return to function earlier Indications Fractures that need operative fixation Inherently unstable fractures prone to re-displacement after reduction (eg. mid-shaft femoral fractures) Pathological fracture Polytrauma (minimise ARDS) Patients with nursing difficulties (paraplegics, v. elderly, multiple trauma)
    27 : Maintain reduction – internal method By.. Nail , plate , screws, ware. Complications Infection Non-union Implant failure Re-fracture
    28 : Maintain reduction – internal method Wires & pins Can be used in conjunction with other forms of internal fixation Used to treat fractures of small bones
    29 : Maintain reduction – internal method Plates & screw Extend along the bone and screwed in place May be left in place or removed (in selected cases) after healing is complete
    30 : Maintain reduction – internal method Nail or rods Held in place by screws until the fracture is healed May be left in the bone after healing is completed
    31 : Stages of Fracture Healing Inflammation & Hematoma Callus Formation Woven Bone Remodeling
    32 : Types of fracture healing Primary : healing of the bone occur by interstitial growth of bone in rigid fixation by plate or nail Secondary : healing occurs with adequate callus formation both interstitial & surrounding, when micro movement occur in stable fixation by POP, cast, locking plate, external fixator. Modern concept is …secondary healing is preferable except intra-articular fracture
    33 : Factors Influencing Healing Systemic Factors ? ? Age ? ? Hormones ? ? Functional activity ? ? Nerve function ? ? Nutrition ? ? Drugs (NSAID)
    34 : Factors Influencing Healing…cont. Local Factors ? ? Energy of trauma ? ? Degree of bone loss ? ? Vascular injury ? ? Infection ? ? Type of bone fractured ? ? Degree of immobilization ? ? Pathological condition
    35 : Fracture healing - operative 1) Reduction and compression Primary bone healing Slow process, rehabilitation rapid, high risk 2) Nailing or external fixation Healing by callus Rapid process, rehabilitation rapid, lesser risk
    36 : Healing Complications Delayed union ? ? Nonunion ? ? Malunion ? ? Post -traumatic arthritis ? ? Growth abnormalities Fracture diseases- joint stiffness, non-uses atrophy, Sudeck osteo-dystrophy,
    37 : Follow up of treatment by POP Judge each case on its own merits Sticky – “Deformable but not displaceable” Union (weeks) Incomplete repair; Part moves as one; Local tenderness; Local pain on stress; See fracture line on-x-ray Consolidation (months) Complete repair; No external protection needed; Upper limb 6/52; Lower limb 12/52; Half for child; Double for transverse fractures Remodelling (years) successfully occur in growing skeleton .
    38 : Indications for operative treatment Current absolute indications: Polytrauma; Displaced intra-articular fractures Open fractures with vascular injury or compartment syndrome Pathological fractures and non-union Current relative indications: Loss of position with closed method; Poor functional result with non-anatomical reduction; Displaced fractures with poor blood supply
    39 : Rehabilitation Restore the patient as close to pre-injury functional level as possible Rest, Elevation, Mobilisation (active/passive) Physiotherapy, Work assessment and re-employment
    40 : THANK YOU ALL
    41 : Special Thanks to Incepta Pharmaceuticals Ltd. Bangladesh

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