Introduction of Fracture & D/L
¡¡¡¡
Definition
?Fracture : complete or incomplete disruption of the continuity of bone
?Dislocation : complete disruption of contact of the joint surface ; the articular surface are no longer in contact
?Subluxation : partial(minor) disruption of contact of the joint surface ; articular contact still remains
Classification of fracture
?Anatomic location : epiphysis, diaphysis, metaphysis, intraarticular
proximal, middle, distal
head, neck, trochanter, shaft, supracondylar, condylar
in femur
?Degree :
1. complete ( common in adult )
2. incomplete (common in child, ex : hairline fracture, buckle fracture, greenstick fracture )
?configuration :
1. transverse (fracture by direct force, avulsion fracture as olecranon or patella fracture)
2. oblique (short fracture line )
3. spiral ( relatively long fracture line, an acute angle of fracture end, wide fracture surface)
4. longitudinal
?Number of fragment
1. simple (linear) fracture
2. comminuted fracture
3. segmental fracture
?Open wound
1. closed fracture
2. open fracture
?Stability
1. stable fracture ( transverse fracture, short oblique fracture )
2. unstable fracture ( spiral fracture, long oblique fracture)
?Displacement
1. displaced fracture
2. undisplaced fracture
# shearing, angulation, rotation, distraction, overriding, impaction
l Classification by mechanism of injury
(1)Direct trauma :
1.tapping fracture ; occur when a weak applied over small area, usually transverse fracture line, ex.nightstick fracture
2. crush fracture ; with extnesive soft tissue damage
extensively comminuted or transeversely
3. penetrating fracture ; produced by projectiles, gunshot
fracture
(2) Indirect trauma :
1. avulsion or tension fracture ; happen to the patella or olecranon when the knee or elbow is forcibly flexed while extensor muscles are contracting
2. angulation fracture ; transverse fracture, may form butterfly fragment
3. rotation fracture ; when a piece of chalk is twisted until it breaks, a characteristic spiral fracture line is produced
4. compression fracture ; T- or Y-shaped fracture (e.g. at the lower end of the humerus or femur)
5. angulation & axial compression fracture ; consist of an oblique component caused by compression and a transverse component caused by angulation -> oblique fracture
6. angulation, rotation & axial compression fracture ; oblique fracture
Special type of Fracture
1. Pathologic fracture : fracture through an area weakened by preexisting disease such as
osteoporosis, infection, primary or metastatic tumor, radiation, disuse, surgical defect
2. Stress fracture : complete or incomplete fracture due to repeated minor stress usually in tibia, fibula, metatarsal, femur etc.
Diagnosis of fracture
?Clinically :
trauma Hx.
pain
swelling
loss of function
deformity
postural change
abnormal mobility & crepitus
neurovascular injury
?Associated injury must examine the brain, spinal cord, nerve, vessel, intrathoracic and abdominal organ
look out the other site fracture
very young child, comatose & uncooperated patient : be careful !
¡¡
Radiological examination
1. at least AP & lat. views are necessary
2. sometimes oblique view or special view is needful
3. in long bone x-ray ; include both side of joints
4. in children ; check the both side x-ray and then compare with normal side
5. CT : is necessary in the spine or pelvis fracture
6. Bone scan : stress Fracture scaphoid Fracture
<Descriptive terms>
1. Site
2. Extent
3. Configuration
4. Displaced or nondisplaced
5. Open or closed
¡¡
Diagnosis of dislocation
1. pain
2. swelling
3. change of normal contour of joint ; flattening of deltoid in
shoulder D/L
4. loss of motion
5. postural change ;
(1) post. D/L of hip
(flexion, adduction, internal rotation & shortening)
(2) ant. D/L of hip
(abduction, external rotation )
6. neurovascular injury ; more frequent than that of fracture,
(1) sciatic nerve injury in posterior D/L of of hip
(2) common peroneal nerve in medial D/L of knee
(3) axillary nerve or brachial plexus in shoulder D/L
(4) Popliteal artery injury in knee dislocation
7. Associated injury
Radiological test in D/L
important test
at least ; AP & Lat. or axial
cautious in associated bony fragment
Fracture healing
1. Healing process of fracture in long bone
1) inflammatory stage (1-3 days)
2) reparative stage ; soft callus (3 wks)
hard callus (3 mo.)
3) remodeling stage (3 yrs)
2. Healing process of fracture in cancellous bone
3. Healing process of intraarticular fracture
Definition of fracture healing
: A process of bone regeneration - the injured tissue is replaced by its own kind and a scar does not form
<1> Inflammatory stage of healing process of Fracture
# begin within 48 hrs & last for 3 - 4 days
# soft tissue envelope (periosteum & surrounding muscles) is torn and blood vessels crossing the fracture line are ruptured
# accmulate hematoma in medulla & beneath elevated periosteum -> rapidly coagulate to form a clot
# necrosis of immediate end of fracture, periosteum, marrow & surrounding soft tissues
--> immediate and intense acute inflammatory response
# inflammatory agents -> vasodilatation, plasma exudation -> acute edema in the region of fresh fracture
# hematoma is organized by granulation (inflammatory cells, fibroblasts, collagen, invading capillaries)
<2> Reparative stage
# hematoma organization is the first step
# hematoma serves primarily as a fibrin scaffold -> repair cells perform their function (protein release) -> stimulus to cell
migration, cell proliferation & matrix formation
# microenvironment is acid -> stimulus to cell behavior ->gradually neutral then to slightly alkaline (ALP)
# Pluripotential mesenchymal cell involve directly in the repair of fracture
# Some cells derived from the cambium layer form the earliest bone esp. in children
# Majority of cells derived directly from endothelium enter the fracture site with the granulation tissue, which invades the region from surrounding vessels
# The cells invade the hematoma and begin rapidly producing the tissue known as callus ( made up of fibrous tissue, cartilage, and young, immature fiber bone)
# Osteogenic cell from cambium layer & osteoblast from endosteum -> callus formation
#Soft callus : at central hypoxic area, formed with cart. tissue -> enchondral ossification
#Hard callus : by intramembranous bone formation, at periphery of the inflammatory area
#Mineralization of callus : calcium hydroxyapatite crystals -> fusiform mass of callus, more rigid
#Clinical union : painless, stable
#radiologically visible callus between fragments
<3> Remodeling stage
# Woven bone replaced by mature lamellar bone, resorption of superfluous or poorly placed trabeculae
# Radiologic union : mature lamellar bone & reconstruction of medullar cavity
# Wolff's law : bone formation at compression site (concave surface, electronegative, osteoblast) & resorption at tension site (convex surface, electropositive, osteoclast)
Healing process to Fracture in cancellous bone
# large surface area, open trabeculae system -> easily invade by osteogenic tissue , abundant cells & blood flow --> healed by primary callus formation from osteoblast at trabeculae
# Hematoma -> neovacularization -> proliferation of osteogenic cells -> calcification & woven bone formation
# nonunion is rare
Healing process of intraarticular Fracture
# Articular surface (hyaline cart.) : healed by fibrocartilage
# Collagenase in synovial fluid : lysing initial clot & callus matrix -> retarding the 1st stage in fracture healing
# Joint motion : induce the motion of fracture fragments and disturb the healing process
¡¡
Factors influencing fracture healing
?all factors influencing the metabolic activities of osteogenic cells
?Systemic factors
?Local factors
<1> Systemic factors
?Age : child fracture -> rapid healing
1)promoting hormones
growth hr. thyroid hr. insulin, anabolic steroid, calcitonin, vitamin A & D
2) retarding ; DM, castration, rickets. hypervitaminosis A & D,
?Systemic infection : retard the union
?Blood dyscrasia : retard
?Chronic debilitation disease : retard
?Central or peripheral nerve paralysis : denervation -> decrease physiologic electric stimulus -> retard
but CNS injury -> increase bone healing
?Anticoagulants : retard
?Exercise
<2> Local factors
?Severity of trauma
?Open fracture
?Segmental fracture
?Soft tissue interposition
?Inadequate blood supply
?Bone necrosis
?Local infection
? Bone disease : pathologic fracture & delay the healing
?Loading of fracture callus : piezoelectric effects -> stimulate & proliferate bone formation and mineralization of callus
?Electric stimulation
?Fracture stabilization
?Bone graft
?Demineralized bone matrix, growth factor
?Inappropriate treatment
¡¡
Treatment of Fracture & D/L
?Emergency care
?Definite treatment
?Rehabilitation
<1> Emergency care
??Airway keep
? Bleeding control
? Splint application (immobilization)
1) protection from further soft tissue injury
2) relieve pain
3) decrease rate of fat embolism, shock
4) easy for transportation & x-ray taking
# Kinds of splint
cast splint ;
upper extremity : short arm, long arm, sugar tong, ulnar gutter
lower extremity : short leg, long leg
Thomas splint, wood splint, wire splint etc.
<2> Definite Tx.
?Principle
1) to have the good reduction & union of fracture fragments
2) to recover the function & cosmoses of extremity
3) possibly return to his vocation in shortest time
?Reduction
?Maintenance
?Rehabilitation
<3> Nonoperative method
???Closed reduction
1) traction in longitudinal axis of limb
2) reverse the mechanism that produced the fracture
3) align the fragments (distal to proximal)
1) Cast immobilization : immobilize the above & below joints
; thumb spica cast, short arm cast, long arm cast, shoulder
spica cast
; complications ; cast sore, circulatory disturbance, nerve
palsy over bony prominence, cast syndrome
(1) skin traction ; Buck's traction, Russel traction,
Bryant's traction etc.
(2) skeletal traction
(3)Functional brace (tibia shaft fracture, distal 1/3 of femur,
humeral shaft fracture)
3) Pin & plaster method
# contraindication : a. no significant displacement
b. displacement of little concern (ex. hemerus surgical neck fracture)
c. reduction cannot be held
d. reduction is not possible (comminuted fx)
e. fx. produced by a traction force (ex. displaced patella fracture)
f. intraarticular displaced fracture
<3> Operative method
?Open reduction & internal fixation
?Closed reduction & IM nailing
?Closed reduction & external fixation
# accepted indication of external fixator
; a. type II, III open fracture
b. associated burns
c. severe bone loss
d. certain fracture requiring distraction
e. limb lengthening
f. arthrodesis
g. infected fracture or nonunion
h. some type of pelvic bone fracture
# complication of external fixation
; a. pin site infection
b. pin loosening and breakage
c. limitation of joint motion
d. neurovascular damage and compartment syndrome
e. malalignment and malunion
f. delayed union or nonunion
?Internal fixation
# wire fixation(tension band wiring, cerclage wiring, K-wire fixation)
# pin fixation(Steinmann pin, Kowles pin)
# screw fixation( cancellous screw, cortical screw, malleolar screw)
# plate & screw fixation(neutralization plate, compression plate, buttress plate,
bridge plate)
# I-M nailing (rigid, flexible, interlocking)
?arthroplasty ; neglected displaced femur neck fracture over 3 wks
femur neck fracture with R.A. or D.A.
4 part fracture of humeral surgical neck fracture
?Advantage of OR : anatomical reduction, early ROM & functional recovery
?Disadvantage :
# infection rate(osteomyelitis, hepatitis, AIDS) is increased
# delayed union or nonuinon due to vascular disruption
# scar
# anesthetic risk
# removal of implant
# neurovascular damage
# refracture due to stress shield effect after plate removal
Indication of Op. method
1. closed reduction is failed or impossible
2. closed reduction are known to be ineffective (ex. Galeazzi fracture Monteggia fracture )
3. displaced intraarticular fracture
4. displaced epiphyseal fracture (S-H type III, IV)
5. multiple injured patient
6. unstable spinal fracture or pelvic fracture
7. to reduce morbidity from prolonged cast or bed rest
8. associated arterial injury
9. pathologic fracture secondary to tumor metastasis
10. major avulsion fracture ( patellar fracture olecranon fracture )
11. nonunion following open or closed treatment
12. to improve nursing care
Contraindication of Op. method
1. active infection or osteomyelitis
2. severe osteoporosis
3. severe comminution that cannot be reduced
4. severe soft injury
5. poor general condition
6. nondisplaced fracture
Treatment of dislocation
1. Always closed reduction is possible under general or local anesthesia
2. Emergently try the reduction as soon as possible
3. Immobilization (cast, splint, traction)
4. associated injury of neurovascular structure
5. complication of dislocation : AVN, degenerative arthritis, heterotopic ossification
6. Indication of open reduction :
# failed closed reduction due to interposition of soft tissue or bone fragment
# redislocation after closed reduction or impossible to maintain the
reduction state
#neurologic deficit after closed reduction
#no improvement of circulation after closed reduction
Complications of Fracture & D/L
1. General Cx. : shock
cardiopulmonary arrest
crush syndrome
bleeding
fat embolism
deep vein thrombosis & pulmonary embolism
gas gangrene
tetanus
cast syndrome
2. Local Cx. : soft tissue injury,
internal organ damage
compartment syndrome
local infection
deformity (nonunion, malunion, shortening of the limb)
refracture
epiphyseal injury
joint stiffness, joint laxity
recurrent dislocation
posttraumatic arthritis
avascular necrosis
heterotopic ossification
Sudek's atrophy
Shock
1. definition : tissue hypoxia due to inadequate tissue perfusion -> damage to major organ
2. classification : hypovolemic, neurogenic, vasogenic, cardiogenic
3. Hypovolemic shock : most commonly encountered in multiple traumatized
patient
: to safely restore adequate blood volume
Fat embolism
1. posttraumatic RDS
2. occur within 72 hrs after trauma
3. 0.5 - 2 % of long bone fracture
4. 5 -10 % of pelvis % femur shaft fracture
5. mortality : > 50 %
6. Pathology : free fat droplet from BM -> circulation through ruptured vein
->embolization on lung, kidney, heart & brain -> respiratory distress
7. Clinical findings of fat embolism
respiratory distress : dyspnea, cyanosis
cerebral sx. : disorientation, coma
skin lesion : petechiae on chest, axilla, neck
fundus : microinfarct
tachycardia, high fever, oligourea
* Triad of early findings : tachycardia, high fever (BT>38'C), fall in PaO2
8. Laboratory findings of fat embolism
PaO2 < 60mmHg
thrombocytopenia, anemia
serum fatty acid increased
Chest PA : snow storm appearance
fat in cryostat-frozen section of clotted blood
lung scan
9. Treatment of fat embolism
# Early stabilization of fracture reduce the fat embolism & ARDS
# Tx for hypoxia : O2 supply & maintain the 70-90 mmHg of PaO2,
# artificial ventilator
# fluid therapy
# massive steroids
# ethanol
# heparin
# low molecular weight dextran
Gas gangrene
1. Clostridium species (esp. C. perfringens)
2. Sx. : latent period 3 days, severe pain, swelling, tachycardia, fever, anxiety
3. muscle necrosis, gas formation in tissue, toxemia or shock, high mortality rate
4. Tx. : thorough irrigation & debridement are very important in open fracture
fluid electrolyte balance
antibiotics (PCN)
hyperbaric O2 therapy
Cast syndrome
£±) due to hyperextension body jacket cast
£²) severe vomiting, electrolyte imbalance
£³) compression of 3rd portion of duodenum by superior mesenteric artery
£´) prevented by frequent position change
£µ) Tx. : cast removal & fluid therapy
Soft tissue injury
£±) Skin injury : open fracture, operative wound, cast sore, bed sore
£²) Muscle & tendon injury
£³) Nerve injury : axillary nerve in anterior shoulder D/L
radial nerve in distal 1/3 humerus fracture
median, radial, or ulnar nerve in supracondyle fracture in children
sciatic nerve in hip D/L
spinal cord in spine fracture
4) Vascular injury : caused by ext force, fracture fragment or dislocated head,
injury during closed reduction, cast or traction
# axillary artery in shoulder D/L
# popliteal artery in knee D/L
# penetrating injury
# Treatment of vessel injury :
a. early reduction in compression and close observation
b. cast removal or fasciotomy due to cast or hematoma
c. emergent repair or reconstruction of ruptured major artery
Compartment syndrome
£±) Def. : a condition in which the function and circulation of tissue within a closed space are compromised by increased pressure within that space
£²) > 30-60 mmHg, > 12 hrs -> necrosis of muscle, nerve & vessels
£³) Classic sign & Sx. : Pain, Pallor, Paralysis, Paresthesia & Pulseless
4 ) Treatment of compartment syndrome
a. Early detection & treatment ; important
b. First stage :
1. reduce the fracture
2. elevate the limb
3. remove all constrictive dressings and casts
4. relieve the joint flexion
c. 2nd stage :
1. fasciotomy
2. epimyosiotomy
3. exploration of vessels
Infection (osteomyelitis)
1 ) Still a Significant Failure rate in treatment of Bone infections despite advances in Antibiotic therapy
2 ) direct infection with open fracture or reconstructive procedure
3 ) Tx of osteomyelitis
# thorough irrigation, debridement in open fracture ( Prevention is important )
# curettage of infected or necrotized tissue
# antibiotics
# continuous suction-irrigation
# antibiotics-mixed bone cement beads
4 ) Complication :
nonunion
pyogenic arthritis
joint stiffness
Delayed union & Nonunion
1 )Def. of delayed union :
Healing takes longer than average for a given bone injury to heal ( 6 months after fracture)
2) Def. of nonunion :
An arrest of healing process & formation of a typical pseudarthrosis or fibrous union at fracture site
3 ) Causes of nonunion
a. open fracture
b. severe comminuted fracture
c. infected fracture
d. segmental fracture
e. pathologic fracture
f. fracture separated by soft tissue interposition
g. fracture in area with poor blood supply
h. extensive gap between fragments
i. Iatrogenic interference with healing process
1. motion on fracture site due to improper fixation
2. immobilized too short period
3. excessive periosteal stripping
4. distraction due to fixation
4 ) Sx. of nonunion : pain during Wt. bearing, tenderness, instability, progressive angulation & deformity , false motion on fracture site
5 ) X-ray findings
a. sclerosis of bone ends at the fracture site
b. absence of any progressive change over 3 months interval
c. increase in the amount of bony atrophy above and below the fracture
site
d. excessive callus formation around fracture site with a lucent interval
through callus
6 ) Tx. of nonunion : immobilization
rigid fixation with IM nailing or compression plate &
screw
accelerates bone induction by bone graft, electrical
stimulation
arthroplasty in femoral neck fracture
Malunion
1) Def : one that has healed with fragments in nonanatomical position
# angular deformity, rotation deformity, shortening of limb
e.g. cubitus varus after supracondyle fracture in humerus
2 ) Shortening of limb
a. shortening of fractured limb than normal side
b. lower extremity ; over 2.5 cm -> limping gait
c. Causes : growth retardation or stop after epiphyseal injury
overriding or angulation of fragments comminuted fracture
bone defect in open fracture
d. Tx : < 2.5 cm -> shoe elevation
> 2.5 cm -> op. ( lengthening of shortened limb or shortening of
normal limb )
Epiphyseal injury
1) Arrest of bony growth & deformity after epiphyseal injury
2) Causes : nonanatomical reduction in Salter-Harris type III & IV
maintenance failure during treatment
Posttraumatic arthritis
1 ) Causes : a) joint incongruity after intraarticular fracture
b) malunion
# anatomical reduction is necessary in intraarticular fracture
2) Tx : analgesics, PT in mild case
3) Arthroplasty (hip, knee, shoulder & elbow joint) in severe case
arthrodesis (ankle & finger ) in severe case
Avascular necrosis
1 ) Def : Bony necrosis due to interruption of blood supply associated microvascular injury after fracture or dislocation
2) Cause : a. excessive periosteal stripping of fragments during operation
b. femoral head after neck fracture or D/L
c. talar head after talar neck fracture
d. proximal fragment of scaphoid fracture of wrist
Sudek's atrophy
1 ) Def : Vague, ill-defined wide spread painful condition after fracture, dislocation, soft tissue , nerve, & artery injury
2) Sx is appeared after recovery of fracture or joint trauma, 2-3 %
pain, redness, edema, paresthesia around injured area, joint stiffness,
muscle atrophy
3) X-ray : mottled osteoporosis
4) Tx : early ROM exercise is important
analgesics
TENS
sympathetic block
Pathologic Fracture
1 ) Def : a fracture involving abnormal bone
2 ) Abnormality
1) Local change : disuse, surgical defect, bony infection, primary or metastatic bone tumors, irradiation
2) Systemic : osteoporosis, rickets, osteogenesis imperfecta, Paget's disease , syphilis, tabes dorsalis
3 ) occurs spontaneously or with minor trauma
4 ) Dx : history taking, PE, x-ray (carefully reviewed), survey for primary disorder
5 ) Tx : depend on location, type of fracture, category of pathology affecting bone
a. Tx. for causes
b. brace
c. operative methods
(esp. metastatic tumor ; pain relieve, easy nursing care )
Stress fracture
1 ) Def : complete or incomplete fracture due to minor repeated stresses
2 ) most common in tibia,
3 ) other sites ; metatarsal bone, femur, pubis, ischium, humerus, ulna, calcaneus, talus etc.
4 ) ballet dancer
marathoner
military recruits
5 ) Symptom : progressive pain & tenderness after repeated stress
6 ) Dx : x-ray, bone scan (early detection)
7 ) Tx : rest & avoidance of stress
analgesics
immobilization with splint
Open fracture
1 ) Def : A break in the integument & underlying soft tissue with communication of the fracture site with outside environment
2 ) Classification
a. Type 1 : small wound of 1 cm or less by low velocity trauma minimal
soft tissue damage
b. Type 2 : more than 1 cm without extensive soft tissue damage
flaps or avulsion, slight or moderate crushing injury
little or no avascular soft tissue
relatively little foreign material
c. Type 3 : extensive and massive size of wound > 10 cm
considerable devitalized soft tissue
considerable amount of foreign material
caused by high velocity trauma
3-A ; extensive soft tissue laceration or flaps but maintain
adequate soft tissue coverage of bone
3-B ; extensive soft tissue loss with periosteal stripping and bony
exposure, usually massively contaminated
3-C ; open fracture with an arterial injury that required repair
regardless of the size of the soft tissue wound
3) Treatment
a. Wound care & prevention of infection are important
b. Cleansing and debridement
c. Treatment of fracture
# int fixation in type 1 or 2(early case)
# ext fixation in type 2 or 3
d. Wound closure
primary closure in type 1 or 2
open in type 3 -> delayed closure
e. Antibiotics
f. Prevention of tetanus