FRACTURE & DISLOCATION:

How can primary physicians play

their roles?

Tri Wahyu Martanto, MD

Dept. of Orthopaedic and Traumatology

Faculty of Medicine, Airlangga University
Dr. Soetomo General Hospital
Surabaya
2017
 The Outline
What we will discuss today

Introduction
What to do as primary physician?
Special consideration
Summary
 The Outline
What we will discuss today

Introduction
What to do as primary physician?
Special consideration
Summary
 Introduction
- Definition -
A fracture is
a break in the structural continuity of bone
 Introduction
- Epidemiology -

Based on mode of injury

There is difference between
dominant cause of injury
between developed and
developing countries

Based on location
(Royal Hospital of Edinburg, 2008)
 The Outline
What we will discuss today

Introduction
What to do as primary physician?
Special consideration
Summary
 What to do ???
Patients with suspected fractures require urgent
and sometimes emergent evaluation to
determine if serious complicating conditions exist
The acute management of uncomplicated
fractures are:
1. Initial clinical assessment
2. Radiographic assessment
3. Immobilization
4. Pain management
5. Patient education and follow-up care
 What to do?

1. Initial Clinical Assessment

Begin the assessment by looking for life-
threatening injuries using the basic approach of
Advanced Trauma Life Support
History for patient without life-threatening
injuries may begin with a focused history:
Mechanism of injury
Localization and characterization of symptoms
Concomitant injuries
Examination do systematically, comparing both
sides if necessary
LOOK: deformity? Swelling? Bruise? open wound?
bone exposed?
FEEL: tenderness? distal neurovascular?
MOVE: false movement?
 Important!!!
Avoid testing crepitation or passive range of
motion or manipulating the affected area to
prevent exacerbating pain, fracture displacement,
soft tissue damage, or neurovascular compromise
General rule: splint it where it lies,
Exception: when distal neurovascular function is
compromised, the physician should promptly
reduce any apparent dislocation or reposition of
the injured extremity followed by proper splint
application for immobilization
 Deformity

Swelling & bullae

Open wound
 What to do?

2. Initial Radiologic Assessment

Plain x-ray
The rule of 2s :
1. 2 joints (proximal and distal of the fracture site)
2. 2 views (combination of AP & lat, or oblique views)
3. 2 limbs (the injured limb and the healthy one)
4. 2 sites (commonly in severe trauma)
5. 2 Occasions (by the time of injuries and sometimes after that)
Obtain advanced imaging when clinical
findings suggest fracture but plain x-ray are
unrevealing, e.g: CT-scan, MRI
Common pitfall: normal physeal line might be misinterpreted as fracture
in pediatric patients
 QUIZ:
Can you name the fracture?

(Example of AP, lateral, and additional oblique view)

 QUIZ:
Can you name the fracture?
 QUIZ:
Can you name the fracture?
 What to do?

3. Immobilization
Why is so important?
Reduce pain
Protect from further injury
Several methods to immobilize: splinting,
casting, bracing, buddy tapping, sling-and-
swathe, skin traction
Remember to always check for distal
neurovascular BEFORE and AFTER the
application of immobilization
 SPLINTING
Can be done using simple
splint or slab made of PoP
or fiberglass
Important rules:
Rigid enough
Long enough (to fix 2 joints or
2 limbs)
Always apply soft and thick
padding on surface with bony
prominent
Splinting in two planes
stabilize better compared to
single plane
 CASTING
(Circular cast) BRACING
BUDDY TAPPING SLING & SWATHE
SKIN TRACTION
 What to do?

4. Pain Management
Pain is the 5th vital sign!
Adequate analgesia is
mandatory for effective pain
control
Acetaminophen or NSAID is
often sufficient for minor to
moderate fractures
More severe pain require
treatment with opioids
Always consider the history of
drug allergy of patients
 What to do?

5. Patient Education & Follow-up Care

What to do next once a fracture and any
associated injuries have been stabilized?

The physician must be able to educate the

patients on the following issues:
The definitive treatment options
consult or refer to orthopedic surgeons
The complications
early, intermediate, and late complication
Fracture Complications
 The Outline
What we will discuss today

Introduction
What to do as primary physician?
Special consideration
Summary
 Special Consideration
1. Open fracture
2. Dislocation
3. Compartment syndrome

What to do???
 Open Fracture

When the fracture

makes contact with
outside world

Must be able to identify and

to classify
Look for the TRIAD of the
flowing blood:
Oozing
Dark-coloured
Fat-bubble sign
 Open Fracture
This is an emergency
Treatment is determined by
the type of injury and the
nature of the wound
All open fractures, no matter
how trivial they may seem,
must be assumed to be
contaminated
WHAT TO DO?
1. Check distal neurovascular
2. Give broad spectrum
antibiotic and anti-tetanus
3. Irrigate the wound with
copious amount of saline
4. Never attempt to insert
back any bone fragment
5. Cover and bandage the
wound
6. Immobilize the fracture
7. Consult or refer for
immediate debridement
 Dislocation
A dislocation is an
abnormal separation of
two adjacent bones
within a joint
Check for distal
pulsation and
neurological status
This is an emergency
Reposition of dislocated
joint must be done
immediately
 Dislocation
WHAT TO DO???
If you are in remote
Attempt closed reduction
If you feel confident and
capable then immobilize

If you are in doubt

Referral to orthopedic surgeon
Immobilize and refer
is possible
 Compartment Syndrome
Fractures of the arm or leg can give rise to severe ischaemia
even if there is no damage to a major vessel. Bleeding,
oedema or inflammation (infection) may increase the pressure
within one of the osteofascial compartments; there is reduced
capillary flow which results in muscle ischaemia, further
oedema, still greater pressure and yet more profound
ischaemia - a vicious circle that ends, after 12 hours or less, in
necrosis of nerve and muscle within the compartment.
 Compartment Syndrome
The classic features of ischaemia
are the five Ps:
Pain on passive movement
Paraesthesia,
Pallor,
Paralysis
Pulselessness

WHAT TO DO??
The threatened compartment (or
compartments) must be promptly
decompressed:
- Remove all cast, bandage, dressing, etc
-Close observation of distal perfusion
- Elevate the limb
- Refer immediately
 The Outline
What we will discuss today

Introduction
What to do as primary physician?
Special consideration
Summary
 Summary
Primary physicians play very important role in
the initial management of fracture and
dislocation
Proper management in initial treatment might
prevent severe morbidity or even mortality in
patients
Good teamwork between primary physicians
and orthopedic surgeons is the key to bring
the best result to the patient
Thank you