ORTHOPE

DICS AND
TRAUMA

Dr Nigus G( GP)
03/13/24
OUTLINE

Fracture
Dislocation
Trauma and mechanism of #
Childhood #
Amputation
 Trauma is a major public health problem
with high disability, death, and societal
cost.
Three peak times of death after trauma

INTRODUC
o 50% within the first minutes of
sustaining the injury
 caused by massive blood loss or

TION
neurologic injury
o 30% within the first few days
 most commonly from neurologic injury
o 20% within days to weeks following
injury
 multi system organ failure and
infection are leading causes
FRACTURE A fracture is a break in the
structural continuity of bone

AND TYPES If the overlying skin remains intact

it is a closed (simple)#

OF
if the skin or one of the body
cavities is breached it is an open
(compound) fracture.

FRACTURE
0pen # is liable to contamination
and infection.
  Type I
wound < 1 cm
 Type II
1-10cm
Type III A
GUSTILO > 10 cm, high energy
CLASSIFICATIO  adequate tissue for coverage
 includes segmental / comminuted
N fractures even if wound <10cm
farm injuries are automatically Gustillo III
Type IIIB
extensive periosteal stripping and requires
free soft tissue transfer
Type IIIC
vascular injury requiring vascular repair
 COMPLETE FRACTURES

TYPES OF INCOMPLETE FRACTURES

the bone is incompletely divided, and the

FRACTURE
periosteum remains in continuity.
EXTENT
BASED ON
ANATOMY

 proximal, shaft, or distal

epiphysis, metaphysis, or diaphysis
BASED ON FRACTURE PATTERN
Transverse # Oblique # Spiral #
• oriented perpendicular • oriented diagonally to • sharp ends with a
to the long axis of the the axis of the bone vertical component
bone

comminuted # segmental Knowing the #

• it is a fracture with • having two #line with a pattern will help to
multiple fragments. bone fragment bn the predict the healing
proximal and distal
portion of the bone and its stability .
… Common fracture pattern
FRACT There is two type of healing

URE
 Healing by callus formation
(commonest)
 Healing by direct union

HEALI
• If the fracture site is absolutely
immobile
• Bone cells directly heal with out

NG
callus formation
 …
Healing by callus formation has 5 stages
1 stage of hematoma formation
2 stage of inflammation and cellular
proliferation
3 stage of soft callus formation
4 stage of hard callus formation (consolidation )
5 stage of remodeling
callus is preossification cartilage that forms in response to
controlled motion ( micro motion at #site )
…

(a) (b) (c) (d) (e)

Fracture healing Five stages of healing: (a)Haematoma: there is tissue damage and bleeding
at the fracture site; the bone ends die back for afew millimetres. (b) Inflammation: inflammatory
cells appear in the haematoma. (c) Callus: the cellpopulation changes to osteoblasts and osteoclasts;
dead bone is mopped up and woven bone appearsin the fracture callus. (d) Consolidation: woven
bone is replaced by lamellar bone and the fractureis solidly united. (e) Remodelling: the newly formed
bone is remodelled to resemble the normalstructure.
FACTORS •age (fast in children) •Smoking and alcohol

AFFECTIN •Location
• (metaphysis > diaphysis)
•Infection

G • (upper L > lower L)

•# pattern

HEALING •Blood flow

•Chronic disease
•Soft tissue interposition
•Bone loss
•Nutritional status
•Drugs
• (NSAID, steroid ,
immunosuppressant
drugs)
INDICATORS OF
# HEALING
•Decreased pain and tenderness
•Decreased mobility bn fragment
•Improved function
•Visible callus on x ray
DISLOCATION
 A dislocation is a complete disruption of a joint so
that the articular surfaces are no longer in contact.
 Subluxations are minor disruptions of joints where
a portion of the articular surface is still in contact
 Dislocation occur with damage to the protective
ligaments and joint capsule
PATHOLOGY AND
MECHANISM OF TRAUMA
Bone is relatively brittle, yet it has sufficient strength and resilience to withstand considerable
stress
Fractures result from:
1 injury;
2 repetitive stress (stress fracture)
3 abnormal weakening of the bone (a pathological fracture).
FRACTURES DUE TO INJURY
Most fractures are caused by sudden and excessive
force, which may be direct or indirect
o With a direct force the bone breaks at the point of impact
o With an indirect force the bone breaks at a distance
from where the force is applied
…
Although most fractures are due to a combination of forces (twisting, bending, compressing
or tension), the x-ray pattern reveals the dominant mechanism
• Twisting causes a spiral fracture
• Compression causes a short oblique#
• Bending results in # with a ‘butterfly’
fragment
• Tension tends to break the bone
transversely
…

(a) (b) (c) (d)

23.1 Mechanism of injury fracture patterns and mechanism: (a) spiral pattern (twisting); (b)
short oblique pattern (compression); (c) ‘butterfly’ fragment (bending) and (d) transverse pattern
(tension).
FATIGUE OR STRESS
FRACTURES
These fractures occur in normal bone which is subject to repeated heavy loading, typically in
athletes, dancers or new military personnels
It is due to small repeated fracture from repeated trauma merging together to cause complate #.
PATHOLOGICAL
FRACTURES

Fractures may occur even with

normal stresses if the bone has been
weakened by a change in its structure
(e.g. in osteoporosis, Paget’s disease)
or through a lytic lesion ( a
metastasis).
HOW FRACTURES ARE
DISPLACED
After a complete fracture, the fragments usually become
displaced, partly by the force of the injury,
partly by gravity and partly by the pull of
muscles attached to them.
Displacement is usually described in terms of
translation, alignment, rotation and altered length:
...

Rotation; it is
Angulation; Translation; lateral Altered length;
rotation around the
angulation of the movement of the shortening/impaction
longtudinal axis of
axis bone fragment
the bone
HISTORY
There is usually a history of injury, followed by inability to use the injured limb,
but beware! The fracture is not always at the site of the injury
Always enquire about symptoms of associated injuries: pain and swelling elsewhere and a
complete Hx and PE should be taken after stabilizing the Pt.
During the secondary survey it will also be necessary to exclude other previously
unsuspected injuries and to be alert to any possible predisposing cause (like a metastasis,
infection).
PHYSICAL EXAMINATION

EXAMINE THE MOST • TEST FOR ARTERY • LOOK FOR • LOOK FOR ONES THE PT IS
OBVIOUSLY INJURED AND NERVE ASSOCIATED ASSOCIATED STABLE HEAD TO
PART. DAMAGE. INJURIES IN THE INJURIES IN DISTANT TOE EXAMINATION
REGION. PARTS. SHOULD BE DONE.
MUSCULOSKELETAL
EXAMINATION

Look Feel Move Measure

Swelling, bruising, tenderness, pulse, both active and passive
deformity, wound, posture sensation, temperature, movement should be
of the distal and crepitus checked
extremity and the colour
of the skin
 1 Is it open or closed
2 Which bone is broken and where( proximal,

DESCRIPTION
shaft ,distal)
(3) Has it involved a joint surface? (extra
articular or intra articular)
(4) What is the shape of the break?( pattern )
OPEN
DISTAL
TF#
 The first thing you should do when you face a
trauma pt is to check the
A AIR WAY
B BREATHING
RX OF C CIRCULATION

FRACTURE D DESABLITY
E EXPOSURE
Secondary survey : AMPLE history; allergy,
medication, past medical history, last meal,
event
 HEMORRHAGIC SHOCK
CLASSIFICATION & FLUID
RESUSCITATION

class Blood loss HR BP urine PH Treatment

I <15% Normal Normal >30ml/hr Normal Fluid

(<750ml)

II 15-30% >100BPM Normal 20-30ml/hr Normal Fluid

(0.75-1.5L)

III 30-40% >120BPM Decreased 5-15ml/hr Decreased Fluid and blood

(1.5-2L)

IV >40% >140BPM Decreased Negligible Decreased Fluid and blood

(>2L)
 INDICATORS OF
ADEQUATE
RESUSCITATION
MAP > 60mmHg
HR < 100BPM
urine output 0.5-1ml/kg/hr
serum lactate levels <2.5mmol/L
DEFINATIVE RX

REDUCTION ( CLOSED OR OPEN)

IMOBILIZATION
( POP CAST, TRACTION ,EX FIX OR
INTERNAL FIXATION)

REHABILITATION
NUTRITION, PSYCOLOGICAL
AND PHYSIOTHERAPY
 •Reduction should aim for adequate apposition and normal
alignment of the bone fragments

REDUCTIO •The greater the contact surface area between fragments the
more likely healing is to occur.
N •There are two methods of reduction: closed and
open
IMMOBILIZA •usually it is the prevention
of displacement.
The available methods of
holding reduction are:
TION
•It is also needed to • Continuous traction.
promote soft-tissue
healing and to allow free • Cast splintage ( POP )
movement of the • Functional bracing.
unaffected parts and to
control pain • Internal fixation.
• External fixation
REHABILITATION

•The objectives are to reduce oedema, preserve

joint movement, restore muscle power and guide
the patient back to normal activity:
 PEDIATRIC FRACTURES

In a pediatric patient, the epiphyseal Reduction and stabilization of epiphyseal Treatment of growth plate fracture
growth plate is unossified and at risk of fractures is critical to minimize requires anatomic reduction of the
fracture. permanent growth disturbances and fragments
deformity.
…
COMPLICAT
IONS OF
FRACTURES
Local complications can be divided
into
• early; arise during the
first few weeks
• late; arise after several
months
 • VISCERAL INJURY
• VASCULAR INJURY
• NERVE INJURY
• COMPARTMENT SYNDROME
EARLY classic features of ischemia are the five Ps
COMPLICAT Pain, Paresthesia, Pallor, Paralysis,
Pulselessness.
IONS
 • FRACTURE BLISTERS
• GAS GANGRENE; Clostridium perfringens

EARLY • PLASTER AND PRESSURE SORES

COMPLICATIO • INFECTION
NS…. • HAEMARTHROSIS
 DELAYED UNION; very little or incomplete
callus formation
• Inadequate blood supply
• Severe soft tissue damage
LATE • Periosteal stripping
COMPLICAT • Imperfect splintage

IONS • Over-rigid fixation

• Infection
 NON-UNION;
in X-ray The fracture is clearly visible but the bone
on
either side of it may show either exuberant callus or

atrophy
LATE
Cause ; inadequate Contact bn # fragment
COMPLICATIO
NS….. improper Alignment
instability bn # fragment ( moment )
MAL-UNION
AVASCULAR NECROSIS
 JOINT STIFFNESS
JOINT INSTABILITY
LATE MUSCLE CONTRACTURE
COMPLICATIO MYOSITIS OSSIFICANS
NS…..
BED SORES
OSTEOARTHRITIS
COMMON UPPER EXTREMITY #

FRACTUR HUMERUS #
ELBOW #
WRIST #
colles #
ES FORE ARM # smith #
monteggia# HAND #
geleazzi # SCAPHOID #
RU# METACARPAL #
PHALENGIAL#
 ELBOW FRACTURE
include distal humerus#, radial head# and olecranon#

 MONTEGGIA FRACTURE;
fracture of the proximal 3rd of the ulna with concomitant radial head dislocation

 GALEAZZI FRACTURE;
fracture of the radius shaft with dislocation of the distal radioulnar joint

 COLLES FRACTURE;
distal radius fracture with posterior (dorsal) displacement of the distal fragment

 SMITH FRACTURE;
distal radius fracture with anterior (volar/ventral) displacement of the distal fragment
LOWE ANKLE FRACTURE

EXTREMIT HIP FRACTURE

FEMORAL HEAD#
FOOT FRACTURE
TALUS#
Y FEMORAL NECK# CALCANEAL #
FRACTUR FEMORAL SHAFT # METATARSAL #
E TIBIAL FRACTURE
AMPUTATI
ON
•Amputation is removing the limb
part or the whole limb from the
body
•Disarticulation is removing the
limb though a joint
INDICATI oDead limb 1. Trauma

ON oDeadly limb
oDead loss
2.
3.
Infection
Malignancy
4. PAD
5. Burn
6. Deformity
( malformation )
GENERAL
PRINCIPLE
•Muscle should be cut at least 5cm distal to the
level of bone section
•Nerve should be cut proximally and allowed to
retract
•Blood vessel should be double ligated and cut
•Bone section should be above the level of
muscle section
•Prosthesis is fitted after a minimum of 8-12
weeks after surgery
COMPLICATION
• Hematoma
• Infection
• Necrosis
• Contracture
• Neuroma
• Stump pain
• Phantom sensation
• Bone overgrowth
‘
.
Thank you