The Scribes Slide-Fracture Classification_Management.pptx

Fracture management

1. Classification and Management of Fractures A PRESENTATION BY UJ/2016/MD/0011 EKEOHA MICHAEL TOCHUKWU

2. Outline Definition Causes Epidemiology Classification Fracture Healing Principles of Treatment Resuscitation Clinical Presentation History Examination Investigations Treatment Modalities Complications

3. Fractures Break in continuity of living bone Break in structural integrity of bone Always caused by a force – trivial or not Very common as a result of – Increasing proliferation of vehicles – MV and MC Disregard to traffic rules Poor road network Non-availability of alternative safe modes of transport

4. Trauma Trauma is an exchange of energy between the body and the environment which exceeds the resilience of the body Force could be direct or indirect

5. Introduction Fractures have been identified as medical problems throughout history Most of Hippocrates' medical essays described the management of injuries, especially fractures Most # treated then by amputation or crude splints

6. Introduction Knowledge of the biological aspects of fracture care expanded greatly during twentieth century Patient expectations have reached unprecedented levels Large, multinational industries have developed around the surgical and medical treatment of fractures

7. Causes Vehicular Accidents Falls Sport injuries Industrial accidents Assault Warfare / projectile injuries Freak accidents

8. Epidemiology Very high morbidity worldwide affecting all age groups and sexes 1.6 million Hip fractures occur yearly worldwide 250,000 hip # occur per year in the US

9. Epidemiology 700,000 painful spine fractures occur per year No organized figures for Nigeria M:F = 3:1 Most occur in young adult males

10. RTA in Nigeria According to available statistics, in 2006, about 4,944 Nigerians lost their lives in 9,114 road accidents 17,390 people sustained injuries also In August, 2006 alone, 1,042 accident cases were reported resulting in 473 deaths and 2,246 injuries 5 of the dead were children

11. JUTH Pattern of Injuries in multiply injured patients (Ozoilo) Head injuries – 71.8% Extremity – 60.6% Chest - 23.3% External – 16.1% Abdominal injuries – 11.7%

12. Classification of Fractures Coexisting skin injury? Closed – no skin injury Open – co-existing breach in overlying skin Degree of force Traumatic – significant force Pathological – Trivial force Stress – Repetitive force Are the ends congruous? Undisplaced

13. Classification of Fractures Displaced – ends are not Translation Angulation Rotation Length Fracture line? Transverse Oblique Spiral Communited and segmental Other classification systems exist

14. Stages of Fracture Healing Tissue destruction &Hematoma formation Inflammation & cellular proliferation Callus formation Consolidation Remodelling

15. Principles Resuscitate Radiology Reduce Immobilize or hold Red uction Regeneration Rehabilitate Each is as important as the other

16. FRACTURE CARE Resuscitate! Airway and cervical control Breathing and Ventilation Circulation and Hemorrhage control Drugs – analgesia, antibiotics, anti-tetanus, anti-gas gangrene Debridement and wound cover if possible Expose in a controlled environment and carry out secondary survey

17. Clinical presentation Demographic data Pain Open wound Loss of function Deformity – rotational or length Swelling Local vascular and neural intergrity

18. Clinical Presentation Painless Fracture could occur Elderly patients Psychiatric patients Neurologically impaired Pathological fractures will present in patients with features of the underlying pathology

19. Investigations Plain radiographs 2 orthogonal views 2 times - pre and post intervention 2 limbs 2 joints – above and below Must be good quality Digital X-rays much better Open fractures packed in sterile dressing before

20. X-rays Defines the Classification of the fracture Helps in the planning of treatment Used to determine the adequacy and monitor treatment chosen Diagnose local bony complication Used to monitor growth in paediatric fractures

21. Investigations PCV GXM U&E, RBS CRP – open fractures CT-scan – complex fractures MRI when indicated – vertebral fractures

22. Drugs Analgesia Anti-Tetanus Antibiotics Anti Gas gangrene

23. Reduce Return fracture ends to as close to anatomical position as possible Essential for fracture healing Must be perfect in peri-articular fracture Not all fracture need reduction Minimally displaced or acceptable Reduction may be useless or dangerous – clavicle Closed or Open Techniques

24. Reduction Techniques ? Gravity - Humerus Closed Manual Manipulation Skin Traction Skeletal Traction Traction Table Femoral Distractor Open manipulation

25. Immobilization Reduction must be maintained to ensure fracture heals in acceptable position Not essential for reduction to be rigid as micro-movement enhances fracture healing Various techniques described and indications must be met as a prerequisite to choice Could be non-rigid, semi- rigid or rigid

26. Immobilization Techniques Slings and other orthosis Casts – POP, Fibreglass ( Dynacast ), Polyurethane or Polyethylene, composite Skin Traction Bryant’s Traction (Gallows) Buck’s Traction Skeletal Traction Classical sites of pin application Used in cases where Ex/Int fix not affordable

27. Immobilization Techniques Also in open fracture Certain Pelvic fracture Complex fracture - Pilon injuries, osteoporotic fracture Severe communition Infected fracture

28. External Fixation Use of a system of pins, wires or screws and rods, bars or circular frames placed outside the body attached across a few fractures to provide stability Main indication is open fracture

29. External Fixation Also used in Vascular injury Segmental fractures Bone Loss Pelvic fractures Infected fractures Multiple fractures

30. Internal Fixation Several described Long attempted but early defeats as a result of poor anaesthesia and infection Later defeats due to poor material selection AO/ASIF has revolutionalized the research into the materials used for and design of implants for practically all fracture in human body

31. Internal Fixation The ideal implant material is Strong – high tensile strength Inert Sterile/sterilisable Non-carcinogenic – long stay

32. Internal Fixation The ductility, malleability, plasticity must be known Materials used presently are Stainless steel Titanium Cobalt-Chromium Alloys Less commonly used are absorbable and carbon based implants

33. Implants Extramedullary Plates Screws Wires Intrameddulary Nails Pins Wires

34. Indications for Internal Fixation Failed conservative treatment Displaced intra-articular fractures Fractures in which internal fixation is superior to other treatment e.g. Fracture of the femoral neck, shaft, both fore-arm bones Pathological fracture Fracture in elderly patients due to risks involved in prolonged immobilization

35. Indications for Internal Fixation Multiple fracture Physeal injuries Associated neuro-vascular injury Complications such as Non-union Mal-union Delayed union

36. Contraindications Osteoporotic bone that is too fragile to allow stabilization by internal or external fixation Soft tissues overlying the fracture or planned surgical approach of poor quality Active infection or osteomyelitis Fracture comminution to a degree that does not allow successful reconstruction

37. Contraindications General medical conditions that are contraindications to anesthesia Undisplaced or stable impacted fractures in acceptable position do not require surgical exposure or reduction except femoral neck fracture Inadequate equipment, manpower, training, and experience

38. Peculiarities in Children Usually as a result of injuries at play Pathological also common Usually incomplete High index of suspicion necessary Growth plate injuries and the resultant angular deformities or length deformities that result

39. Peculiarities in Children Conservative treatment usually suffices ORIF rarely needed and usually extra-medullary implants used Usually an incresed rate of growth in fractures limb after healing Healing is faster and remodelling is rapid as such acceptable reduction has a wider range than adults

40. Rehabilitation Physical Psychological Social Occupational

41. COMPLICATIONS Any unwanted result that increases the morbidity and the risk of mortality of a disease arising from physical, endocrine, metabolic or psychological effect

42. Complications of Fracture Classified as Early or Late Local or General/ systemic Early complications are Vascular injury Nerve injury or entrapment Muscle rupture Tendon / ligament injury Compartment syndrome

43. Complications of Fracture Haemarthrosis Infection – AOM, Tetanus, sepsis Gas gangrene Visceral injury # blisters Late complications are Delayed union Non union Malunion

44. Complications of Fracture Avascular necrosis Muscle contracture Joint stiffness Osteoarthritis Algodystrophy Myositis ossificans Volkmann’s Ischaemic contracture

45. Conclusion Fractures are a very common Orthopaedic problem worldwide A knowledge of the basic presentation and techniques of management will help us “first, do no harm” The knowledge and application of fracture care is at best sparse among medical practitioners the scourge of TBSs is still real and as dangerous as ever