PATH - Bony Injuries (Fractures) (8p) PDF
PATH - Bony Injuries (Fractures) (8p) PDF
PATH - Bony Injuries (Fractures) (8p) PDF
BONY INJURIES
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FRACTURES & FRACTURE HEALING:
- Aetiology:
o *Traumatic Injury
o Pathological Fracture – (Osteolytic Bone Metastasis, or Osteoporosis)
- Mechanisms of Fracture Healing:
o Fracture
o 1. (1-3days) - Haematoma & Inflammation (Blood Clot + Fibrin Mesh)
o 2. (1-3weeks) - Soft Callus (Deposition of Osteoid + Granulation Tissue + Fibroblasts)
o 3. (1-2mths) - Hard Callus (Mineralisation of Osteoid)– NB: VISIBLE ON XRAY
o 4. (>2mths) - Remodelling of Woven Bone with Lamellar Bone
- Bone Remodelling:
o Bone remodels in response to:
Calcium requirements in body...and
Mechanical Stress
Physical Activity (Stress)
Nutrition
Vitamin D
Age
Hormones (Eg. PTH, PHRP)
o Resorption – destruction of old bone matter by Osteoclasts
o Apposition – deposition of new bone matter by Osteoblasts
- Clinical Features:
o Emergency Because:
Risk of Infection - If an ‘Compound/Open Fracture’.
Some require treatment to heal.
Risk of NV-Compromise – can pull/tear/compress/rupture surrounding nerves/vessels.
Risk of Compartment Syndrome - Bleeding into muscle compartments Compresses
blood vessels and nerves May lead to “Crush Syndrome”
NB: Crush Syndrome: Muscle Ischaemia/Necrosis due to Compartment Syndrome Pain,
Swelling, Inflammation, DIC, Rhabdomyolysis Limb Amputation.
- Treatment:
o Reduction (Either Open or Closed Reduction)
o Immobilisation (Splint/Cast/Rod/Pins/Brace/etc)
o Analgesia
o Rest Physio
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- Morphology of Fractures:
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FRACTURES - GENERAL PRINCIPLES
❏ mechanism: remember the process leading to the fracture
• traumatic
• pathologic - tumour, metabolic bone disease, infection, osteopenia
• stress - repetitive mechanical loading
CLINICAL FEATURES OF FRACTURES
❏ pain and tenderness
❏ loss of function
❏ deformity
❏ abnormal mobility and crepitus (avoid)
❏ altered neurovascular status (important to document)
INITIAL MANAGEMENT
❏ ABCDEs
❏ limb - attend to neurovascular status (above and below)
❏ rule out other fractures/injuries (especially joint above and below)
❏ rule out open fracture
❏ take an AMPLE history - Allergies, Medications, Past medical history, Last meal,
Events surrounding injury
❏ analgesia
❏ splint fracture - makes patient more comfortable, decreases
progression of soft tissue injury, decreases blood loss
❏ Imaging
RADIOGRAPHIC DESCRIPTION OF FRACTURES
❏ rule of 2s
• 2 sides: bilateral
• 2 views: AP and lateral
• 2 joints: above and below the site of injury
• 2 times: before and after reduction
❏ patient identification
❏ identify views
❏ open or closed (gas in soft tissue = open)
❏ site
• which bone
• if diaphyseal decribe by thirds : proximal/middle/distal
• extra-articular: diaphysis/metaphysis
• intra-articular
❏ type
• spiral - rotational force, low energy (# line > 2x bone width)
• oblique - angular and rotational force
• transverse - direct force, high energy
• comminuted (> 2 pieces) - direct force, high energy
❏ soft tissue
• calcification, gas, foreign bodies
❏ displacement (position of distal fragment with respect to proximal)
• apposition/translation - describes what percentage of surfaces remain in contact
• angulation - describes which way the apex is facing
• rotation - distal fragment compared to proximal fragment
• shortened - due to overlap or impaction
DEFINITIVE MANAGEMENT
❏ goals – “Obtain and Maintain Reduction”
• reduce
• stabilize
• rehabilitate
successful unsuccessful
rehabilitate
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FRACTURES - GENERAL PRINCIPLES . . . CONT.
Reduction
❏ is reduction necessary?
• may not be for clavicle, fibula, vertebral compression fractures
❏ reduce when amount of displacement is unacceptable
❏ imperfect apposition may be acceptable while imperfect alignment is rarely acceptable
❏ closed when possible
❏ indications for open reduction - remember NO CAST
• N - Non-union
• O - Open fracture
• C - neurovascular Compromise
• A - intra-Articular fractures (require anatomic reduction)
• S - Salter-Harris III, IV, V and/or special situations depending on site
• T - polyTrauma
• others
• failure to reduce closed
• cannot cast or apply traction due to site (e.g. hip fracture)
• pathologic fractures
• fractures in paraplegics for nursing access
• potential for improved function with open reduction with internal fixation (ORIF)
• complicatoins
• infection
• non-union
• new fracture through screw holes
• implant failure
Stabilization
❏ stabilize the fracture site but do not completely immobilize the limb if possible
❏ external stabilization
1. splints/tape
2. casts
3. traction
4. external fixator
❏ internal fixation
1. percutaneous pinning
2. extramedullary fixation (screws, plates, wires)
3. intramedullary fixation (rods) - biomechanically advantageous
Rehabilitation
❏ to avoid joint stiffness
❏ isometric exercises to avoid muscle atrophy
❏ range of motion (ROM) for adjacent joints
❏ CPM following rigid fixation of fracture allows joint motion to prevent stiffness for intra-articular fractures
❏ after cast/splint removed and fracture healed ––> resistive muscle strengthening
❏ evaluate bone healing (clinical, x-ray)
OPEN FRACTURES
❏ EMERGENCY!
❏ fracture communicates with skin surface
❏ examine fracture carefully to classify (Table 1)
Table 1. Classification of Open Fractures
Size Soft Tissue Injury Antibiotics
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FRACTURES - GENERAL PRINCIPLES . . . CONT.
❏ must get to O.R. within 6 hours, since risk of infection increases after this time
❏ wound usually left open to drain
❏ re-examine, with possible repeat I&D in 48 hours and closure if appropriate
FRACTURE HEALING
Normal Healing
weeks 0-3 hematoma, macrophages surround fracture site
weeks 3-6 osteoclasts remove sharp edges, callus forms within hematoma
weeks 6-12 bone forms within the callus, bridging fragments
COMPLICATIONS OF FRACTURES
Table 3. Complications of Fractures
Early Late
Local Neurovascular injury Malunion
Infection Nonunion
Compartment syndrome Osteonecrosis
Implant failure Osteomyelitis
Fracture blisters Heterotopic ossification
Post-traumatic arthritis
Reflex sympathetic dystrophy (RSD)
Systemic Sepsis
Deep vein thrombosis (DVT) / pulmonary embolus (PE)
Fat embolus
Acute respiratory distress syndrome (ARDS)
Hemorrhagic shock
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FRACTURES - GENERAL PRINCIPLES . . . CONT.
Treatment
❏ remove constrictive dressings
❏ bivalve casts down to skin and spread open
❏ place limb at level of heart
❏ emergency fasciotomy to release compartments if difference between diastolic blood pressure
and compartment pressure is less than 30 mmHg (treat within 4-6 hours of onset symptoms)
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FRACTURES - GENERAL PRINCIPLES . . . CONT.
Mechanism
❏ occurs following disruption of blood supply to bone
❏ occurs especially in those bones extensively covered in cartilage which rely on intra-osseous blood supply
and distal to proximal blood supply, e.g. head of femur, proximal pole of scaphoid, body of talus
❏ results in ischemia
❏ pathologic changes include resorption, subchondral fractures and loss of cartilage
SHOULDER
GENERAL PRINCIPLES
❏ shoulder is a complex 4 part joint
• glenohumeral joint
• acromioclavicular (AC) joint
• scapulothoracic joint
• sternoclavicular joint
❏ examination should involve each of the joints in isolation
❏ the joint is highly mobile therefore decreased stability
❏ dislocations and subluxations following trauma are common
❏ rotator cuff and tendon degeneration are more common than osteoarthritis (OA)
❏ may be referred pain from C-spine
Physical Examination of the Shoulder
❏ LOOK - inspect both shoulders anteriorly and posteriorly, clavicle, deltoids, scapula (SEADS)
❏ FEEL - for tenderness, swelling, temperature changes, muscle characteristics (include all joints and bones)
❏ MOVE - Active/Passive
Active ROM
• forward flexion and abduction
• external rotation (elbows at side and flexed 90 degrees, move arms away from midline)
• internal rotation (hand behind the back, measure wrt. level of the spine)
Passive ROM
• abduction – 180 degrees
• adduction – 45 degrees
• flexion – 180 degrees
• extension – 45 degrees
• internal rotation – level of T4
• external rotation – 40 - 45 degrees
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