Principles-fracture-management - Presentation slide (2).pdf

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1. Principles of Fracture
Management
Widiyatmiko

2. Introduction
Orthopaedics is
concerned with
bones, joints,
muscles, tendons and
nerves – the skeletal
system and all that
makes it move

3. Introduction
Scope :
•Congenital &
developmental
abnormalities
•Infection & inflammation
•Arthritis & rheumatic
disorders
•Metabolic & endocrine
disorders
•Tumours
•Sensory disturbance &
muscle weakness
•Injury & mechanical
derangement
Subdivision :
•Traumatology
•Orthopaedi :
1.Adult Reconstruction
2.Oncology
Orthopaedic
3.Pediatric Orthopaedic
4.Spine
5.Hand & Microsurgery
6.Sports Injury

4. In Emergency Room…
•Assess all trauma patient for possibility of orthopaedic case!
•If the patient need operation  prepare as soon as possible!
1. Informed consent
2. Tell to fast at least 6 hours prior to op
3. Make IV line
4. Tetanus prophilactic
5. Antibiotic & analgetic
6. Blood check (SYSMEX for < 40 y.o, complete for > 40 y.o and < 14
y.o)
7. Urine check
8. Cross match & blood reservation in blood bank
9. EKG ( for > 40 y.o)
10. Chest X-Ray, with expertise for < 14 y.o
11. Complete the medical record ! (under resident supervision)
12. IPD or paediatric consultation ( for > 40 or < 14, sometimes no
need)
13. Anesthesiology consultation

5. General Principles of Fracture
Treatment
1.First, Do No Harm
2.Base Treatment on Accurate Diagnosis
and Prognosis
3.Select Treatment with Specific Aims
4.Cooperate with the “ Laws of Nature “
5.Make Treatment Realistic and Practical
6.Select Treatment for You as an
Individual

6. Aphorism of Fracture
Management
1.Think before you start. Are you
treating the patient? Or merely the x –
ray?
2.Think before you reduce . Have you
worked out how to do it? And how to
hold your reduction?
3.Think before you hold. Is your splint
necessary? Is it harmful?
4.Think before you operate . Are you
good enough? Are your facilities good
enough?

8. What is fracture ?
•Fracture is a break or disruption in
the continuity of a bone.
Fracture divide in 2 types :
•Closed fracture
•Open fracture

9. Fracture Description
Anatomic location includes the name of the bone or the bones
involved.
Regional location – diaphysis ,metaphysis ,epiphysis;
intraarticular or extraarticular and physis.
Directions of the fracture lines – transverse ,oblique and
spiral.
Conditions of the bone – comminution # ,pathological #
,incomplete # ,segmental # ,fracture with bone loss ,fracture with
butterfly fragment ,stress # and avulsion #
Extent – Fracture may complete or incomplete
Relationship of the fracture fragments to each other –
undisplaced or displaced
eg:translated,angulated,rotated,distracted,overriding and
impacted.

10. Examination of The Affected Parts
First We LOOK
Then We FEEL
Then We MOVE
•Neurological examination
•Diagnostic imaging
•Blood Test
•Synovial fluid analysis
•Bone biopsy
•Arthroscopy
•Electro diagnosis

11. Adult and Children Fracture

12. Children Fracture
1.Fracture more common .
2.Stronger and more active periosteum .
3.More rapid fracture healing .
4.Special problems of diagnosis .
5.Spontaneous correction of certain residual
deformities .
6.Differences in complications .
7.Different emphasis on methods of treatment
8.Torn ligament and dislocation less common .
9.Less tolerance of major blood loss

13. Adult Fracture
1.Fracture less common but more serious .
2.Weaker and less active periosteum .
3.Less rapid fracture healing .
4.Fewer problem of diagnosis .
5.No spontaneous correction of residual
fracture deformities .
6.Differences in complication .
7.Differences emphasis on methods of
treatment.
8.Torn ligament and dislocations are more
common .
9.Better tolerance of major blood loss .

18. CLOSED FRACTURE
The fracture is not exposed to
the external environment.
The soft tissue injury ranges
from minor to massive .
Closed soft tissue injury are
commonly graded by the
methode of Tscherne (grade 0
until grade 3 )

19. TREATMENT
Protection Alone without
reduction or immobilization
Immobilization by External
Splinting without reduction
Closed Reduction by Manipulation
Followed by Immobilization
Closed Reduction by Continuous
Traction Followed by
Immobilization
Closed Reduction Followed by
Functional Fracture – Bracing

20. TREATMENT
Closed Reduction by manipulation
Followed by External Skeletal
Fixation
Closed reduction by Manipulation
Followed by Internal Fixation
Open Reduction Followed by
Internal Skeletal Fixation
Excision of a Fracture Fragment
and Replacement by an
Endoprosthesis

22. OPEN FRACTURE
•The fracture is exposed to the
external environment.
•The amount of soft tissue
destruction is related to the
level of energy imparted to the
limb during the traumatic
episode.
•Describe with Gustillo-
Anderson grading system.

24. OPEN (COMPOUND)
FRACTURES
Goals
•Prevention of infection
•Healing of the fracture
•Restoration of function

25. Steps in management
•ABC included resucitation and
immobilisation
•Assess neurovascular status of
the limb
•Swab wound
•Photograph & Cover wound  
•Tetanus prophylaxis
•Give IV antibiotics

26. •1 . All open fractures are treated as emergencies.
•2. Most studies demonstrate that cultures
obtained on admission are of little help. The
most important cultures are obtained after
initial surgical debridement.
•3. The basic prophylactic antibiotic should be a
broad spectrum cephalosporin.
•4 . Generally, primary closure should not be
formal but may be considered in Grade I
fractures only if adequate debridement and
irrigation have been done. Delayed primary
closure at 5 to 7 days is performed in Grade II
and Grade III injuries.

27. •5. If there is any doubt about adequate
debridement, LEAVE THE WOUND
OPEN!!! THOROUGH DEBRIDEMENT
AND COPIOUS IRRIGATION is
mandatory in the initial treatment of all
open fractures. For Grade II and III
fractures, generally use pulsatile jet
lavage. Exception for soft tissue injuries
which can compromise wound coverage
if there is swelling of the tissue. This is
not a reason to not clean the wound- a
toothbrush can be used on the exposed
bone.

28. •6. Rigid stabilization of fractures
is indicated in Grade III
fractures and many types of
fractures in polytraumatized
patients. The type of fixation
should be determined by the
resident and the staff based on
the nature of the injury and bone
involved.

31. WHAT IS POLYTRAUMA ?

32. ObjectivesObjectives
Establish the principles for assessing Establish the principles for assessing
the patient with musculoskeletal the patient with musculoskeletal
injuries.injuries.
Establish treatment priorities.Establish treatment priorities.
Identify the importance of Identify the importance of
musculoskeletal injuries in the musculoskeletal injuries in the
multiply injured patient.multiply injured patient.

33. Emergency in Orthopaedic
•Emergency : trauma cases
- Life threatening
- Limb treatening
•85 % of blunt trauma
affect musculoskeletal
system
•Life saving before limb
saving

34. Key QuestionsKey Questions
•How do musculoskeletal injuries How do musculoskeletal injuries
impact on the primary survey?impact on the primary survey?
•What are my priorities?What are my priorities?
•What are my management What are my management
principles?principles?

35. Assessment of the Polytrauma
Patient
Primary Survey
–A irway with cervical spine control
–B reathing
–C irculation with control of hemorrage
–D isability (neurological state)
–E xposure (take the patient clothes off)

36. Primary survey Primary survey
management management
The 3 The 3 SS’s’s
SStop the bleeding!top the bleeding!
SSplint the extremityplint the extremity
SStabilize the pelvistabilize the pelvis

37. Primary Survey &
Resuscitation

Recognize and control hemorrhage
•Direct pressure
•Splint fractures
•Fluid resuscitation
BE AWARE OF REPERFUSION INJURY!

38. Primary Survey &
Resuscitation
Adjuncts : Fracture immobilization

Goals
•Hemorrhage control
•Pain relief
•Prevent further soft tissue injury

Apply splint early, but avoid delay in
resuscitation.

Be careful in dislocation

39. Adjuncts : X-Rays

Determinited by patient’s condition

Obtain AP pelvis early if
hemodynamically abnormal and no
obvious source of bleeding
Primary Survey & Resuscitation

40. Secondary Survey
•History
A M P L E
•From Head to toe examination
•Every orifice must be examined
•Don’t forget the back!

41. Secondary Secondary
SurveySurvey
LookLook
Feel Feel
ListenListen
For What?For What?

42. For What?For What?
LookLook
Deformity Deformity
Pain Pain
TendernessTenderness
Wound(s)Wound(s)
FeelFeel
CrepitusCrepitus
Skin flaps Skin flaps
Neurologic Neurologic
deficit deficit
PulsesPulses
Listen Listen
Doppler signalsDoppler signals
BruitBruit

43. Life- Threatening
Injuries

Major pelvic disruption with
hemorrhage

Major arterial hemorrhage

Crush syndrome (rhabdomyolysis)

44. Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
•Posterior pelvic structures disrupted
•Pelvis open : vessels, nerves,rectum,
skin
•Mechanism of injury
–Motorcycle
–Pedestrian
–Crush
–Falls > 12 feet (3.6 meters)

45. Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive
Bleeding

46. Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive
Bleeding

47. Pelvic
Wrapping

48. Life Threatening
Musculoskeletal Trauma
Main Arterial Rupture
1.Trauma
- sharp, blunt
2Examination
- Artery pulse, Doppler
- Ankle / brachial index
3.Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint

49. Life Threatening
Musculoskeletal Trauma
Crush Syndrome

Myoglobinuria
Metabolic acidosis, ↑K,
↓Ca and coagulopathy
Compartment syndrome

IV fluids, alkalization of
urine

50. Limb- Threatening
Injuries

Open fracture and joint injuries

Vascular injuries

Compartment syndrome

Neurologic injury

51. What are my early What are my early
concerns?concerns?
Vascular compromise Vascular compromise
Open fracturesOpen fractures

52. Limb Threatening
Musculoskeletal Trauma
Open Fractures

Apply appropriate splintApply appropriate splint
Cleanse / debride (now or later)Cleanse / debride (now or later)
Consider time factorConsider time factor
Obtain orthopaedic consultObtain orthopaedic consult

53. Limb Threatening
Musculoskeletal Trauma
Open Fractures
Classifying the injury
Gustilo’s classification (Gustilo et al,
1990)

54. Open Fracture grade 1

55. Open Fracture grade 2

56. Open Fracture grade 3A

57. Open Fracture grade 3B

58. Open Fracture
grade 3C

59. Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
•Objectives :
- Prevention of infection
(sepsis/osteomyelitis)
- Promote bone healing
- Restoration of function

60. Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
•4 essentials are :
1. Wound irrigation & debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound coverage

61. Open Fracture
Complicated case
Not proper initial management

62. Limb Threatening
Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation
Reduce fracture(s)Reduce fracture(s)
Splint fracture(s)Splint fracture(s)
Assess by DopplerAssess by Doppler
Obtain consult (time Obtain consult (time
is critical)is critical)
Consider Consider
angiographyangiography

63. Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

64. Management
•Muscle necrosis : 6 h
•Warm & Cold
Ischemic
•Reimplatantation &
Revascularization
•Proper amputee
management!
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

65. Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
•Fractures of the arm or leg 
ischemia
•Infarcted muscles  fibrous tissue
(Volkmann’s ischemic contracture)

66. Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Clinical features
•Elbow, forearm bones, 1/3
prox. of tibiae, multiple
fractures of the foot or hand,
crush injuries &
circumferential burns
•Five Ps
•The presence of a pulse does
not exclude the diagnosis
•Be careful in unconscious
patient !

67. Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Treatment
•Decompression
•Open fasciotomi

68. Limb Threatening
Musculoskeletal Trauma
Dislocations
•Displacement of bone from normal joint
•Location : hip, shoulder, elbow, finger,
patella, knee, ankle, acromioclavicular
•Sign : loss of normal shape &
loss of movement

70. Posterior Hip Dislocation

71. Neurologic Injury

Due to fracture /dislocation
•Posterior shoulder : Axillary nerve
•Posterior hip : Sciatic nerve
Recognize injury and immobilize
Early orthopaedic consult

Careful reduction, if possible →
reassess and splint

72. Limb Threatening
Musculoskeletal Trauma
Massive skin avulsion

73. Abdominal flap
following skin avulsion
of the hand

76. Limb Threatening Musculoskeletal Trauma
Massive skin avulsion

77. ‘Kelirumologi’ in Fracture
Management

78. Pitfalls

Occult injuries

Occult blood loss

Compartment syndrome

79. Case 1 : Male, 40 y.o

81. ICD 9-CM 79.63, 93.44

87. Summary

Primary Survey : Identify life-
threatening
Injuries

Secondary Survey : Identify limb-
threatening injuries

Mechanism of Injuries : History
important

Orthopaedic consult

Early immobilization