CLINICAL DIAGNOSIS OF FRACTURE AND GENERAL PRINCIPLE OF MANAGEMENT OF FRACTURE

REFERENCE -S DAS
- google
- Mercer's textbook of orthopaedics and trauma

1. CLINICAL DIAGNOSIS OF FRACTURE BY DR MANMATHA NAYAK JUNIOR RESIDENT GOVT MC COLLEGE,KOTTAYAM KERALA

2. HISTORY 1) AGE- Epiphyseal separation – children Greenstick # - children Dislocation - adult Fractures - at any age 2) THE AMOUNT AND NATURE OF VIOLENCE How did it occur ?? Mechanism of force ??

3. Green stick #

4. How forceful was the injury ?? * pathological #-violence is not severe enough to cause # femoral neck #- senile osteoporosis subtrochanteric #- pagets dz femoral shaft # - 2ndary carcinoma

5. Nature of violence –direct a) tapping in nature-transverse # b) crushing – communuted # -indirect a) twisting – spiral # b) bending force-transverse/ oblique # c)bending +axial compression-butterfly fragment d) twisting+angulation+axial compression-short oblique # - muscular

6. Muscle contracts against resistance may lead to # Ex- patella,olecranon ,lesser trochanter of the femur 3) PAIN- in # pain is felt only during movement of # site Pain -least in impacted and greenstick # -unbearable and constant in dislocation 4) LOSS OF FUNCTION- Unable to move the fractured limb He cannt put weight on it In Dislocation –unable to move the joint even slightly

7. 5)DEFORMITY OR SWELLING # and dislocation often presents with swelling or deformity

8. LOCAL EXAMINATION The injured side should always be compared with sound side

9. INSPECTION 1)ABNORMAL SWELLING AND DEFORMITY- Deformity- is due to displaced # fragments Swelling- is dt hematoma 2) ATTITUDE- In certain # patients adopt particular attitude # NOF – limb externaly rotated Posterior dislocation of hip- thigh is in flexion ,adduction and internal rotation

10. 3)SHORTENING- Dt overlapping of fracture fragments 4) OVERLYING SKIN- Skin intact or not??? Intact- closed # Not intact -# hematoma communicating to outside-Open# Edema , bullae,blebs are quite common dt interference with venous return Echymosis also appears within a few days after a # or dislocation

11. PALPATION 1)TENDERNESS- Local bony tenderness is valuable sign of # Elicited with relation with bone not with the soft tissue All throughout the length bone is palpated

12. 2)BONY IRREGULARITY- Whole bone is palpated To look for any irregularity-such as sharp elevation,gap etc. Definite sign of # 3) ABNORMAL MOVEMENT- This is also definite sign of # Can be elicited by moving one fragment against other

13. 4) CREPITUS- It is a sensation of grating which may be felt or heard ,when the bone ends are move against each other Other condition which produce crepitus- Ex Hematoma,surgical emphysema,gas gangrene,oa ,tenosynovitis and charcots joint

14. 5) PAIN ELICITED BY MANIPULATING FROM DISTANCE- a) by rotating – in case of humerus or femur b) by squeezing-both bones of leg and forearm c ) by axial pressure in the line of bone-in metacarpal and metatarsal # 6) ABSENCE OF TRANSMITTED MOVEMENTS- Assessed by rotating humerus and femur with flexed elbow or knee respectively by palpating the tubercle of humerus or trochanter of the femur

15. 7) SWELLING- Characteristic should be noted - wheather bony swelling swelling arises from neighbouring joint ??

16. MEASUREMENT 1)LONGITUDINAL- To know if there is any shortening 2)CIRCUMFERENTIAL- To now if there is any wasting dt injury * While taking measurement the sound limb should be kept in the same position as the affected limb * Always good to measure the healthy limb first * measurement should be marked with skin pencil before the use of measuring tape

17. Longitudinal measurement

18. * Measurement should be at the same level in both the limbs in case of circumferencial measurement

19. MOVEMENTS Both active and passive movement should be tested Good – no bony or joint injury Stiffness of the joint is a complication of the # and may be dt-intraarticular and periarticular adhesions,myositits ossification,sudecks osteodystrophy

20. INVESTIGATIONS A) X RAYS- minimum 2 view Ap /lateral Some time oblique and other special views B)CT SCAN – C)MRI-too expensive

21. GENERAL PRINCIPLES OF MANAGEMENT OF FRACTURE

22. GOAL OF FRACTURE M/M Restore the anatomy back to its normal or as near to normal as possible There should not be any functional disability to the pt following the treatment of fractures

23. MANGEMENT OF SIMPLE FRACTURES can be managed with conservative or operative methods A) CONSERVATIVE METHODS For undisplaced #,incomplete #,impacted # Cuff and collar sling- for upper limb # Strapping for # clavicle,finger #,toe # Pop slab NSAIDS

24. Cuff and collar sling

25. Buddy strapping

26. B)OPERATIVE – For displaced # CLOSED REDUCTION OR OPEN REDUCTION 1)Closed reduction- Adopted usually for simple frctures Technique followed is traction and counter traction method Continous traction is used for reduction of fracture Ex gallows traction for # sof in children,skeletal traction for adult SOF

27. Gallows traction

28. Skeletal traction

29. Once the # is reduce it has to be retained in position till # unites by pop,continuous traction ,or by using functional brace Rehabilation is by physiotherapy and exercises once the fracture unitess 2)Open reduction Indiacated once the conservative m/m fail or when there are specific indication

30. INDICATIONS- Absolute- failed closed reduction - displaced intraarticular # -type 3 and 4 epiphyseal injury - major avulsion# - nonunion Relative -multiple # - for better nursing care -delayed union - to avoid prolong bed rest - loss of reduction

31. METHODS OF OPEN REDUCTION- After the exposure the # is redued by direct or indirect methods the # is reduced without exposing by positioning and traction over the fracture table s,skeletal traction etc PRINCIPLES OF OPEN REDUCTION( by lambotte ) Exposure-the # is adequately exposed through a proper approach Reduction of # fragments under direct vision Temporary stabilization-of the # using k wire done first if necessary

32. Definitive stabilization using palte ,screws or intramedullary nails ,k wire , ss wire etc done later, Rehabilation process is same as closed mm of fractures CONTRAINDICATION OF OR- - Infection -small fragments - soft tissue damage - poor general and medical condition

33. OPEN FRACTURES Orthopaedic emergency CLASSIFICATION- 1)GUSTILO AND ANDERSONS TYPE 1- wound <1 cm TYPE II- wound 1- 10 cm, soft tissue normal TYPE III-wound > 10 cm soft tissue are devitalized and contaminated

34. Type 1

35. TYPE II

36. TYPE IIIA

37. TYPE IIIB

38. TYPE IIIC

39. TYPE IIIA- with extensive soft tissue injury but with adequate soft tissue to cover the # bone TYPE IIIB-extensive soft tissue damage and loss - bone cannot be covered TYPE IIIC-with vascular injuries 2)TSCHERNE CLASIIFICATION 3)AO CLASSIFICATION

40. APPROACH IN OPEN FRACTURES- General examination-vitals Examination of other system- Then examination of open #

41. AIMS OF M/M To convert the contaminated wound into clean wound and thus help to convert an open # into a closed one To establish union in good position To prevent infection APPROACH Stabilise the vital and general condition pt first Keep the wound covered with proper sterile bandages until the patient is ready for surgery Open # are surgical emergency and sx to be done once the pt is fit

42. DEBRIDEMENT-consists of following steps Exploration of wound Excision of all non viable tissue CIrteria to assess tissue viability color –pink –pale consistency-firm-flabby capacity to bleed-+,- contractility-+,-

43. Evacuation-of foreign bodies like dirt,glass,stones,pebbles etc. Fb are source of infection may invite aforeign body reaction Hence they hav to be removed by a through irrigation External fixators are used for fracture fixation after debridement - help to stabilize # fragments - allow daily wound inspection and dressings - permits procedure like ssg for wound covering - allow soft tissue healing and early mobilisation

44. EXTERNAL FIXATOR

45. ANTIBIOTICS ,ANALGESICS,TETANUS PROPHYLAXIS External fixation can be used as definitive treatment of fracture,or can be removed after 2-3 weeks if soft tissue is healed for definitve procedure like plate ,screw ,interlocking nail etc.

46. APPROACH TO A POLYTRAUMA CASE Initial evaluation A- AIRWay B-breathing C-circulation D- disability E-Exposure F-fracture examination G-go back to the beginning for a2ndary survey H-help

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