TRETMENT OF FRACTURE – GENERAL PRINCIPLES (remo) (1).pptx

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1. TRETMENT OF FRACTURE – GENERAL PRINCIPLES Dr.Narendra Shirsath

2. Treatment of injuries can be categorised into three phases: * Phase I: Emergency care * Phase II: Definitive care * Phase III: Rehabilitation Emergency Care (Phase I) a) Assessment of patient: * Airway and * bleeding and breathing * Circulation and central nervous system examination * Chest and abdominal injuries * Fractures and other injuries b ) Immediate treatment of : *shock * Haemodynamically stabilisation of patient c ) Splinting: * Splinting fractures to immobilise the affected area * Elevating the affected part or limb and applying mild compression to control bleeding d) Investigation to know fractures and other injuries * xray *ultrasound * mri

3. Definitive Care (Phase 2) Aim: To establish a union and restore normal functioning without causing deformity Fundamental Principles of Fracture Treatment: a) Reduction b) Immobilisation c) Preservation of function Methods of Treatment: a) Treatment by functional use of the limb: - No need for immobilisation and can use the limb e.g., ribs. b) Treatment by immobilisation only e.g. fracture clavicle, fracture surgical neck humerus ( undisplaced fracture) c) - Treatment by closed reduction and immobilisation with plaster casts. d ) Closed reduction and percutaneous fixation - K wires. e ) Open reduction and internal fixation (ORIF) f ) Minimally invasive open surgery (MIS) g ) Primary joint replacement.

4. Reduction of fractures - To get the fixation, proper aliment n good unuin requires reduction of fracture - imperfect angulatory aligment or rotational mal alignment are not acceptable . Bone to bone contact should be there for union Method of reduction 1) Closed manipulation 2) C ontinuous traction - It is used to counter the force which may not allow reduction to happen or forces that would cause Redisplacement e.g. IT fracture neck femur 3) open reduction – ORIF INDICATION FOR OPEN REDUCTION Absolute Failure of closed reduction Displaced intraarticular fracture Some displaced epiphyseal injuries (type 3 n 4) Major avulsion fracture Non union Fracture of necessity eg . Talus fracture, lateral humerus condyle fracture, IT fracture

5. Relative a) delayed union b) Malunion c) Multiple fractures d) Pathological fractures e) Where closed reduction is known to be ineffective eg . Fracture neck of femur f) Fracture with neurovascular injuries Immobilisation of fracture The Reason for immobilization of fracture 1) To prevent displacement or angulation 2)To prevent movement that might interface with the union 3)To relieve pain B) The method of immobilization of fracture 1)Strapping eg . Phalynx 2)Sling eg . Clavical fracture 3)Plaster cast 4)Functional bracing eg . PTB 5)Splints n traction

6. Plaster cast Plaster of paris ( Gypsum salt) is used .It is in dry form after wetting it to be applied on the Limb/part in the given shape. The plaster sets in a given shape after drying. Fundamental principles to be remembered while applying a plaster cast * Immobilise the joints above and below the fracture. * Immobilise joints in a functional position. * Pad the the adequately especially over bony prominances . Complications of plaster treatment Impairment of circulation (tight cast) figure Plaster sores/wound Blisters inside plaster Opreative methods - ORIF/MIS Implants used in treatment of fracture kuntschor’s nail f) rush nail Interlock nails with bolts g) Gamma nail V nail h) PFN Encler nail i ) Elastic nail/tens Rush nails

7. Plates and Screws a) compression plates b) Buttress plate c) Locking compression plate Special implants Others DHS a) steel wires PHILOS plate b) K wire Condylar blade plate c) external fixator Spoon plate d) Illizarov – ring/wires Cobva plate REHABILITAION OF FRACTURED LIMB Rehabilitaion of traction limb begins at the time of injury and goes on till maximam possible functions have been regained It consists of a) joint mobilization b) muscle re-education exercises -- 1)During immobilization 2) after removal of immobilization c) functional use of limb/gait training in case of lower limb injury

8. OPEN FRACTURE DEBRIDEMENT OF WOUND EXTERNAL FIXATOR DEFINITIVE PROCESS AFTER WOUND HEALS PHYSIOTHERAPY

9. Management of open fracture Dr.Narendra Shirsath

10. Treatment of open fracture Phase 1 – Emergency care At the site of accident 1) stop bleeding by applying firm pressure using a clean piece of cloth 2) The wound is washed with clean tap water or saline n covered with clean cloth 3) The fracture is splinted B) In the emergency department –( shock treatment if any) 1) wound care 2) splintage 3) prophylactic antibodies ( broad spectrum preferred) 4) tetanus prophylaxis 5) parentral analgesia 6) xray n other investigation are required Phase 2- definitive care 1) wound defridement --skin graft/skin flap for closure of wound 2)definitive wound management --primary suturing secondary suturing

11. PLAN OF WOUND CLOSURE IN OPEN FRACTURES

12. Fracture management 1 –External fixator 2 –ORIF PHASE 3 – Rehabilitation a) Joint mobilization b)Muscle exercise during immobilization and after removal of immobilization c) Mobilization of injured limb

13. SPLINTS AND TRACTIONS Dr.Narendra Shirsath 1 .Cramer wire splint 2.Thomas splint 3.Bohler Brown splint(BB splint) 4.Dennis Brown splint( DBsplint ) 5.Cock up splint 6.Knuckle Bender splint 7.Toe raising splint 8.Volkmans splint Emergency immobilisation Fracture femur immobilisation and transplant Fracture femur immobilisation Congenital tallipes equinovarus (CTEV treatment) Radial nerve palsy Ulnar nerve palsy Foot drop Volkmanns ischemic contracture

14. 9.Fourpost collar 10.Aeroplane splint 11.SOMI brace 12.ASHE(Anterior spinal hyperextension) 13.Taylors brace 14.Milwaukee brace 15.Bostan brace 16.Lumbar corset 17.Lumbar brace Neck immobilisation for cervical spine injury Brachial plexus injury Cervical spine injury Dorsolumbar spine injury Dorsolumbar immobilisation Scoliosis Scoliosis Backache- spondylolisthesis Backache

15. Traction Objective of traction A)Reduction of fracture and dislocation and their maintainance . B)For immobilisation of painful and inflammed joint. C)For prevention of deformity. Types of traction 1)Skin traction - Contraindicated in skin damage,deep vein thrombosis,vascular deficit and neurological deficit. 2)Skeletal traction

16. Comparison between skin and skeletal traction Points Skin traction Required for Mild moderate force Age used for children Applied with Adhesive plaster Applied On skin Common site Below knee Weight permitted up to 3-4Kg Used for Short duration Skeletal traction Moderate to severe force Adults Steinman pin,k wire Through bone Upper tibial pain Up to 20Kg Long duration

17. Traction system and their uses Name Gallows traction Brayants traction Russells traction Backs traction Perkins traction 90-90 traction Well leg traction Dunlop traction Smith traction Calcaneal traction Metacarpal traction Head Halter traction Crutchfied traction Halo pelvic traction Use Fracture shaft of femur in children below 2years Fracture shaft of femur in children below 2years Trochantric fracture Conventional skin traction Fracture shaft femur in adults Fracture shaft femur in children Correction of adduction or abduction deformity of hip Supracondylar fracture of humerus Supracondylar fracture of humerus Open fracture of ankle and leg Open forearm fracture Cervical spinal injuries Cervical spinal injuries Scoliosis

18. Recent advances in the treatment of fracture AO is Swiss term meaning-Association for osteosynthesis ASIF is English counterpart-Association for the study of internal fixation Basic guiding principles By achieving stable fixation of fracture,a limb can be mobilized early,thereby avoiding the disadvantages of immobilisation

19. What is fracture disease The disadvantages of immobilisation like stiffness of joints,muscles wasting is termed fracture disease What is tension side of a fracture bone The side which is subjected to a distracting force once a fracture occurs ,in away it tends to open up on that side What is tension band principle The principle of converting a tension (Distracting)force in to a compression force Dr.Narendra Shirsath

20. Dynamic compression can be achieved by A)Tension band wire B)Tension band plate In 90s the concept of rigid fixation is replaced by stable fixation Absolute or relative stable fixation To avoid damage to blood supply ,direct open reduction is replaced with indirect closed reduction

21. Intramedullary nail is a load sharing device Now a days biodegradable screws and plates have arrived for use which are made of special plastic

22. ILIZAROVS Technique (Ring fixation) Principle -Distraction osteosynthesis The fracture union can be achived by the site of osteosynthesis ( eg.a fracture) requires either a controlled distraction or a controlled compression This is a dynamic force, when properly applied causes the dormant mesnchymal cells at the nonunion site to differenciate into functional osteoblast this results in bone synthesis and fracture healing Dr.Narendra Shirsath

23. ILIZAROV Theory Any lining tissue when subjected to constant stretch under biological conditions can grow to any extent Biological conditions are provided by A)Aligning the fracture with minimal damage to its vascularity B) Performing osteotomy of the bone without damaging its periosteal and endosteal blood supply ( corticotomy )

24. Distraction or compression is carried out at the rate of 1mm/day to 1/4mm four times a day Illizarav technique is useful in the management of following condition A)Limb lenghthening B)Non union C)Deformity correction D) Osteomylitis with bone gap E)Arthrodesis

25. ILIZAROV Technique Advantages Immediate load bearing A healthy viable bone in place of devascularised bone Correction of more than one problem by one stage operation Disadvantages Inconvinience Long duration of treatment Pin track infection Nerve palsy by pin insertion or traction Joint stiffness caused by the external fixator

26. Apporoach to à patient with limb injury - DR.Narendra Shirsath Casualty management of a trauma victim Firstly - As soon as patent arrives one must assess person as a whole. GC/TPR/BP A - Airway B- Breathing, Bleeding. C- Leve of consciousness (CNS) Glasgo coma score, chest injury . D- Abdominal injuries E-Excretory system - kidney, urethra pehis . F- Fractures n Bony injuries

27. Common fractures at different age.

28. Mechanism of injury and fractures/ dislocation

29. I njuries with charcteristics deformity

30. What are the signs & symptoms of a fracture? a) Pain . b) S welling c) Deformity d) T enderness Direct pressure indirect pressure springing test axial pressure. e) Bony irregularity f) Abnormal mobility & crepitus g) Absence of transmitted movements . One must see the fracture is purely traumatic close or open fracture and or pathological fracture .. One must assess neurovascular damage/injuries.

31. Some commonly used special views

32. F racture commonly missed

33. Feature Fresh fracture Old fracture Pain Severe and acute Mild,intermittent Swelling/bruising Prominent Usually resolved X-ray Sharp well defined Blurred edges Callus formation Absent Present Mobility at site Abnormal movement possible Usuallly stable Treatment Immobilization possible surgery May need corrective surgery

34. A pproach to a patient with limb injury

35. Treatment in emergency department ( Casualty ) 1) P roper and assessment of patient quick assess TPR-BP ABCDEF BP (Vital parameters) 2) Treatment of shock if any 3) S plintage to fracture for transportation to x-ray . (Investigation) parental 4) Analgesics (IV/on)) Antibiotics in open fractures & woul 6) Tetanus for Pophylaxis 7) Immediate treatment for nerve injury, Vascular injuries & joints dislocation. Definitive treatment of fractures after patient settle down.

36. Complications of fractures The complications of fractures can be divided into Immediate , Early and Late . Immediate Complications of fractures. (Hypovolemic shock) - Hypovolemic shock is major following fractures of major bones. Cause The cause of hypovolemia could be external haemorrhage or internal haemorrhage

37. Management- Put start two large bore intravenous cannulas immediately. -Start IV fluids - RL preferably Colloide - BT. L ocalise the site of bleeding." Do Xray chest, & abdomen & penis (portable x) USG Abd , chest if required HRCT/CT abd & brain if required. If required emergency Caparrotomy may be carried out. 1 External fixator for pelvic injury. An emergency angiography & embolisation of The bleeding vessel is performed to control bleeding from deeper vessels.

38. ARDS Adult respiratory distress syndrome Dr.Narendra Shirsath It can be a sequelae of trauma with subsequent shock Cause - The exact mechanism is not known, but it is s upposed to be due to release of inflammatory mediators which cause disruption of microvasculature of the pulmonary System. S ign & symptoms -. Onset usually 24 hours after injury Tachypnea Laboured breathing. Investigation Arterial P02 <50 %% chest X ray- diffuse pulmonary infiltrate, Management 100% oxygen & assisted ventilation - Complications -- Cardiorespiratory failure & death.

39. FAT EMBOLISM SYNDROME Causes :- The fat globules may originate from bone marrow or adipose tissue. The pathogenesis is not clear but it seems l ikely that @release of free fatty acids (by action of lipases the neutral fat) which induces a toxic vasculites followed by platelet-fibrin thrombosis actual obstruction of small pulmonary vessels by Consequences: fat globules. - Presenting features Cerebral type - pulmonary type Cerebral type - patient becomes drowsy, restless, disoriented & "gradually goes into a state of coma. Pulmonary type- Tachypnoea , tachycardia petechial rash - front of neck, anterior axillary foly chest or conjunctiva → Respiratory failure & death. .

40. Diagnosis – Strong suspicion in polytrauma patient. tachycardia Tachypnea . signs of retinal artery emboli (striate haemorhager & exudates) Sputum & urine may reveal - fat globules. Xray chest snow storm appearance . Blood po 50mm Hg Treatment Respiratory support . Heparinisation . IV low moleculer weight derstran [ Lomodex 20] corticosteroids. IV 5% dextros solution with 5%. alcohol - helps in emulsification of fat globules.

41. Deep vein thrombosis and pulmonary embolism Cause Immobilisation following trauma leads to venous stasis Which results in thrombosis of veins. Sign & symptoms of DVT High index of suspicion old age & obese patients leg Swelling & calf tenderness. -calf tenderness may get exaggerated by passive dorsiflexion of Homan's sign Definitive diagnosis -- Venography Colour doppler study venous system. S ign & symptoms of pulmonary embolism High index of suspicion old age & obese patient. Immobilised old dyspnoea develop usually 4-5 days after accident . There may be chest pain or haemoptysis.

42. Treatment of DVT- 1-Limb elevation 2- Elastic bandage to limb / stockinett . 3- Anticoagulant therapy. Treatment of pulmonary embolism. ① Respiratory support ② Heparin Therapy. 2 →for prevention of DVT early fixation of fractures, early active mobilisation of extremity.

43. CRUSH SYNDROME Dr.Narendra Shirsath - This syndrome results from massive crashing of the muscles commonly associated with crush injuries sustained during earthquakes, aiv raids, mining and such incidents. A similar effect may follow the application of torniquet for an excessive period. Cause - C rushing of muscles results in entry of myohaemoglobin into the circulation which precipitates in renal tubules, leading to acute renal tubular necrosis.

44. Consequences - Acute tubular necrosis produces signs of deficient renal functions - scanty urine, apathy, restlessness and delirium. It may take 2-3 days for these features to appear. Treatment Gradual release of touriquet & proper use of a tourniquet. - If oliguria develops, the patient is treated as for acute renal failure.

45. Vascular injuries and skeletal traumа Dr.Narendra Shirsath

46. Management of vascular injury to limb

47. Consequences of arterial injury - 1) No effect - if collateral circulation is good . 2) Exercise ischemia 1 Vascular claudication. (ischaemic pain ) 3) Ischaemic contracture, eg , DIC 4) Gangrene Diagnosis - Signs in the disted Cimb distal to the fracture . Pain pulse absent+Colour doppler for Confirmation . Pallor parasthesias paralysis . management High index of suspicion. Urgent stops strande should be taken for stabiliation of fracture & treatment for vessels

48. INJURY TO NERVES Causes of n erve damage- 1- By the agent Causing the fracture ( eg . bullet) 2- By direct pressure of fractured ends. 3- Traction injury at time of injury on manipulation. 4- Entrapment in callus at the fracture site. Nerve injuries & skeletal trauma Consequences Damage to the nerve may be Neuropraxia A xonotmesis N eurotmesis .

49. Nerve injuries & skeletal trauma

50. Compartment syndrome Dr.Narendra Shirsath The limb contain muscles in compartments enclosed by bones, fascia and interosseous membrane. A rise in fracture within these compartment due to any reason may jeopardise the blood supply to the muscles and nerve within the Compartment - known as compartment syndrome -Osseo facial compartment -Eaton & Green cycle for compartmen syndrome.

51. Causes The rise in Compartment pessure Can be due to a) any injury leading to edema of muscles. b) fracture haematoma within . ischemia to the compartment leading to muscles oedema. Diagnosis -High index of suspicion . -Excessive pain not relived with analgesics . -Stretch test positive . -Tense compartment . - Hyposthesia in the distribution of nerve . -Muscle weakness . -Compartment pressure>40 mm of water.

52. Treatment limb elevation Active toe (finger movements for prevention In establised cases fasciotomy fibulectomy . DELAYED and Nonunion - Causes of delayed & nonunion and Their common sites. Types of nonunion - Ⓐ and b

53. Delayed union When a fracture takes move them the used time to unite is delayed union. Non union When a fracture fails to unite maximum upto 6 months, it is known as non union. Sign & Symptoms of non-union 1.presence of mobility at the fracture site after sufficient time after fracture treatment . 2. Presence of pain at fracture site on using the limb Nonunion may be painless if pseudojoint is formed between fracture ends. 3. Deformity 4. The nonunion can be declared after serial examination & absent signs of fracture healing.

54. 1.Atroplic 2.Hypertrophic TYPES

55. Diagnosis 1-Physical signs-a) mobility b)Tenderness c)deformity 2-X-ray 3-CT/MRI / Ultrasound . Oblique views done under Fluoroscopy may show an unhealed fracture better than Conventional AP & Lateral views . Treatment 1.Open Reduction + refracturing of fracture ends + reduction with fixation and bone grafting 2.Ilizarov technique . 3.Non symptomatic & not hampering function of limbs does not require any treatment. eg , Clavicle nonunion , scaphoid nounion .

56. MALUNION Dr. Narendra Shirsath Defination - When a fracture does not unite in a proper position is known as malunited fracture Cause -Improper treatment . Consequences – 1.Deformily 2.Shortening of limb 3. limitation of movements . Treatment ① Surgical Correction ② If does not hamper activity & limitation of movement can be leave as it is.

57. SHORTENING Dr.Narendra Shirsath Causes- 1-Malunion 2-Crushing-Actual bone loss 3-Growth defect. Treatment 1-If shortening < 2cm - only shoe raise 2-if shortening >2cm a-old age-shoe raise b-Young age-Corrective surgery.

58. AVASCULAR NECROSIS Dr.Narendra Shirsath Blood supply of some bones is such that the vascularity of a part of it is seriously jeopardised following fracture resulting necrosis of that part

59. Radiological changes of AVN Sclerosis of necrotic area. Deformity of bone . osteoartritic changes - diminish joint space, osteopyhytes Treatment – AVN Can be prevented by early treatment. If AVN occurs following measures can be taken 1.Delay weight bearing 2.Revascularisation procedures 3. Excision of avascular segment of bone where doing So does not hamper functions. eg scaploid . 4.Total joint replacement or Arthrodesis.

60. STIFFNESS OF JOINTS Dr.Narendra Shirsath Shoulder Elbow & knee are particularly prone to stiffness following fractures. Causes 1-Intra-articular and periarticular adhesions secondary to immobiliation , mostly in intra articular fractures . 2-Contracture of muscles around a joint because of prolonged immobilizaton . 3-Tethering of muscle at the fracture siteeg -Quadriceps. 4- myositis ossificans

61. Consequences Stiff joints hamper normal physical activity of patient. Treatment 1-Heat Therapy a) Hot fomentation b) Wax bath . c) Diathermy. 2-Ice pack 3-Exercises 4-Manipulation under general anaesthesia . 5-Surgical intervention for- a)excision of intra-articular adhesions ( arthroscopically) b)Excision of extra articular bone block . c)Lengthening of contracted muscle d)Joint replacement if secondary osteoarthritic pain of joint .

62. REFLEX SYMPATHETIC DYSTROPHY ( SUDEK'S DYSTROPHY ) Dr.Narendra Shirsath *It is a group of vague painful condition Observed as a sequel of trauma Signs and symptoms- a)Pain b)Hyperaesthesia c)Swelling d)Tenderness. Early stage - skin becomes red, shiny & warm. L ate stage - Progressive atrophy of skin , muscle & nails, Joint deformity & stiffness

63. Treatment 1-Reassurance of patient . 2-Physiotherapy 3-Ice fomentation 4- In some cases beta blockers . 5- In resistant Cases sympathetic blocks .

64. MYOSITIS OSSIFICANS Dr.Narendra Shirsath This is ossification of the haematoma around a joint, resulting in the formation of bone restricting joint movements , often completely . Causes- It occurs in cases with severe Injury to a joint especially when the Capsule and periosteum have been stripped from bone. Massage following trauma is a factor known to aggrevate myositis .

65. Consequences - - Stiftness of joints. -loss of movement of joint . Radiologically - - A ctive myositis -margins of bone mare are fluffy. -Mature- myositis - bone appears trabeculated with well defined margins . Treatment Early active stage- rest and nsaids Late stage- physiotherapy Matured myositis- surgical excision