This document provides information on bone fracture management. It discusses the clinical features of fractures including signs and symptoms as well as imaging techniques used to evaluate fractures such as X-rays, CT scans, and MRIs. It describes different fracture classification systems including the Tscherne classification for closed fractures and the Gustilo classification for open fractures. The document outlines treatment approaches for fractures including closed and open reduction, immobilization methods like casting, bracing and internal/external fixation, as well as postoperative exercise and management of open fractures.
This document provides information on bone fracture management. It discusses the clinical features of fractures including signs and symptoms as well as imaging techniques used to evaluate fractures such as X-rays, CT scans, and MRIs. It describes different fracture classification systems including the Tscherne classification for closed fractures and the Gustilo classification for open fractures. The document outlines treatment approaches for fractures including closed and open reduction, immobilization methods like casting, bracing and internal/external fixation, as well as postoperative exercise and management of open fractures.
This document provides information on bone fracture management. It discusses the clinical features of fractures including signs and symptoms as well as imaging techniques used to evaluate fractures such as X-rays, CT scans, and MRIs. It describes different fracture classification systems including the Tscherne classification for closed fractures and the Gustilo classification for open fractures. The document outlines treatment approaches for fractures including closed and open reduction, immobilization methods like casting, bracing and internal/external fixation, as well as postoperative exercise and management of open fractures.
This document provides information on bone fracture management. It discusses the clinical features of fractures including signs and symptoms as well as imaging techniques used to evaluate fractures such as X-rays, CT scans, and MRIs. It describes different fracture classification systems including the Tscherne classification for closed fractures and the Gustilo classification for open fractures. The document outlines treatment approaches for fractures including closed and open reduction, immobilization methods like casting, bracing and internal/external fixation, as well as postoperative exercise and management of open fractures.
management Prof. Dr. Mohammed Sh. Al –Edanni Orthopedic surgeon Clinical feature
1.History of injury 2.Clinical examination • Clinical Local signs examination • General signs • Pain and tenderness. • Shock • Swelling • hemorrhage. • Deformity. • Associated • Loss of function. injury to brain, • Bruising. spinal cord or • Abnormal move.. viscera. • Crepitus. Imaging feature of the fracture • 1.Plain X – ray • 2.Special imaging: • It is mandatory, • Tomography. • C.T scan. • MRI • Radioisotope Why Classify? • 1.As a treatment guide 2.To Assist with Prognosis 3.To Speak A Common Language With Fracture Classification… You go from x-ray….
To… Treatment Implant options Results Two types of fracture • Closed Fractures • Opened fracture Closed Fractures Fracture is not exposed to the environment All fractures have some degree of soft tissue injury Commonly classified according to the Tscherne classification Tscherne Classification ● Grade 0- negligible soft tissue injury ● Grade 1- superficial abrasion or contusion ● Grade 2- deep contusion from direct trauma ● Grade 3- Extensive contusion and crush injury with possible severe muscle injury, compartment syndrome Tscherne Classification • Grade 0 • Grade 1
– Minimal soft – Injury from within
tissue injury – Superficial – Indirect injury contusions or abrasions Tscherne Classification • Grade 2 • Direct injury • More extensive soft tissue injury with muscle contusion, skin abrasions Tscherne Classification • Grade 3 – Severe injury to soft tisues – -degloving with destruction of subcutaneous tissue and muscle – Can include a compartment syndrome, vascular injury Open Fractures A break in the skin and underlying soft tissue leading directing into or communicating with the fracture and its hematoma Commonly described by the Gustilo system Gustilo Classification Type I - skin opening of 1cm or less, minimal muscle contusion, usually inside out mechanism Type II - skin laceration 1-10cm, extensive soft tissue damage Type IIIA - extensive soft tissue laceration(10cm) but adequate bone coverage Type IIIB - extensive soft tissue injury with requiring flap advancement or free flap Type IIIC - vascular injury requiring repair Type I Open Fractures Inside-out injury Clean wound Minimal soft tissue damage No significant periosteal stripping Type II Open Fractures Moderate soft tissue damage Outside-in mechanism Higher energy injury Some necrotic muscle, some periosteal stripping Type IIIA Open Fractures High energy Outside-in injury Extensive muscle devitalization Bone coverage with existing soft tissue not problematic Note Zone of Injury Type IIIB Open Fractures • High energy • Outside in injury • Extensive muscle devitalization • Requires a local flap or free flap for bone coverage and soft tissue closure • Periosteal stripping Type IIIC Open Fractures
• High energy • Increased risk of amputation and infection • Major vascular injury requiring repair How to manage fractures 1) Reduction 2) Hold (stabilized) 3) Exercise 1)Reduction of the fracture. • The principles:- • 1. Reduction should be early. • 2. Slightly displaced fractures do not need reduction. • 3. Alignment of # is more important than apposition. • 4. Intra- articular # should be reduced as near to perfection . Two methods of fracture reduction
• Closed reduction. • Open (operative) reduction. Reduction by three maneuvers Traction of the distal • Operative correction part ,then is indicated in:- Reposition of the • 1.Failure of close bone fragments & reduction. lastly • 2.Intra-articular Alignment (correct fracture. the rotation of the • 3.Some avulsion # limb in each plane) 2)How to hold (stabilized) the reduced The aim:- fracture • The methods: 1.To alleviates pain . 2.To ensure that • 1.Continuous traction. union takes place in • 2.Cast good position. splintage(plaster). • 3.Functional bracing. • 4.Internal fixation. • 5.External fixiation 1) Continuous traction • Methods of • Complications of traction: traction: ● Traction by gravity ● vascular problem: alone. especially very old & ● Skin traction. the very young. ● Skeletal traction. ● Nerve injury: Traction by gravity alone. Skin traction. Elastoplasts is applied to the skin of the leg & hold on with a bandage, traction is by cord. this traction produces a pull of up to 5 kg. Skeletal traction- A wire or pin is inserted through the bone distal to the fracture & traction is • applied --- via hook or a stirrup. 2) Cast splintage(plaster). • Types • Complications: • 1.Tight cast--- • Plaster of paris (pop) vascular • fiberglass splint . compression. It need ton split the cast down to skin. • 2.Pressure sore • 3.Skin laceration or abrasion Plaster of paris (pop) • fiberglass splint is hemihydrated calcium sulphate, it reacts with water to form hydrated calcium sulphate which • 3) ofFunctional segments bracing: a cast are applied only over the shafts of the bone, leaving the joint free, metal or plastic connects the cast segments which allow movements of the joint in one plane. • 4) Internal fixation: This is an operative fixation of bone fragments by screws, pins, plate, wire, intramedullary nail.
Indications: Un reduce fractures . Unstable fractures like displaced ankle # & traction injury like patella & olcranon #. Fractures that prone to non union eg. Femoral neck #. Pathological # Poly trauma patient to minimize the risk of ARDS. Fracture in patient who present nursing difficulties (paraplegics, multiple injuries & the very elderly). Internal fixation Internal fixation Complications of internal fixation ➢ Infection. ➢ Non union. ➢ Implant failure, implant may be break if subjected to stress eg. early walking. ➢ Refracture, if implant removed early.
• The implant should be kept for at least
one year and 18 or 24 months safer 5)External fixation: • A fracture is held by transfixing pins, which pass through the bone above & below the fracture site & are attached to an external frame.
Indications: 1) FX associated with sever soft tissue damage. 2) FX associated with nerve or vessel damage. 3) Severely comminuted & unstable #. 4) FX of the pelvis. 5) Infected FX. External fixation Complications of ext. fixation
● Pin tract infection--- this needs regular
cleaning of the pin entry sites. ● Delayed union--- because: **The fragments are held apart by the rigid fixator. **There is reduced load transmission through the bone III. Exercise • It restores function to the injured part and also to the patient as a whole. • The aim 1) Reduce oedema. 2) Preserve joint movement. 3) Restore muscle power. 4) Guide the patient back to normal activity the soft tissue treatment •Elevate and exercise •Never dangle. •Never force Principles of treatment of opened fracture 1. Antibiotic prophylaxis. 2. Wound (soft tissue) debridement. 3. Stabilization of the fracture(the bone). 4. Early wound cover. Antibiotic prophylaxis A second or third generation of cephalosporin, given 6 hourly for 48 hours, will suffice.
If the wound is heavily contaminated, it is wise
also to give gentamicin or metronidazole & to continue treatment for 4-5 days. Wound (soft tissue) debridement *clean the wound from the foreign material. *remove devitalized tissue. *The wound are cleaned with detergent solution. *The wound extended proximally & distally *Dead muscles must be excised. Dead muscles can be recognized by:- 1. Purplish discoloration. 2. Its doughy consistency. 3. Its failure to contract when stimulated. 4. Its failure to bleed when cut. Wound (soft tissue) debridement *Fragments of bone should be removed only if they are totally detached. *Bleeding vessels *A cut nerve is best left undisturbed *Wound closure. To close or not close the skin this can be a difficult decision!! Small (Grade I) wounds that are uncontaminated be sutured or. Skin graft. All other wounds must be left open. The wound is lightly packed with sterile gauze and is inspected after 3-5 days If it clean, sutured or skin grafted(delayed primary closure). Grade III wounds may have to be debrided more than once and skin closure may call for advanced plastic surgery Stabilization of the fracture Grade I& II --- can be treated in the same way as closed injuries. Internal fixation may be used if indication Grade III ---- external fixation is a safest way to achieve sibilization of fracture
