Transcript Fractures and Fracture Management

Fractures and Fracture
Management
Resident Orientation Course 2012
Presented By Dr. Shinouri
Outline
• Definition of Fracture
• Radiographic and clinical description of
Fractures
• Classification of Fractures
• Treatment of Fractures
Definition of Fracture
• Disruption in the integrity of living bone, involving
injury to the bone marrow, periosteum and adjacent
soft tissues
• Described radiographically and clinically
Radiograph and Clinical
Descriptions
• Anatomy: Described in relation to the bones involved
and the location within the bone (diaphysis,
metaphysis, physis, epiphysis)
• Articular surface involvement: Does the fracture have
intra-articular involvement?
Anatomy and Articular Surface
• Which bone?
• Thirds (long bones)
– Proximal, middle, distal
third
• Anatomic orientation
– Proximal, distal, medial,
lateral, anterior, posterior
• Anatomic landmarks
– Head, neck, body / shaft,
base, condyle
• Segment (long bones)
– Epiphysis, physis,
metaphysis, diaphysis
Epiphysis
Physis
Metaphysis
Diaphysis
(Shaft)
Articular
Surface
Radiograph and Clinical
Descriptions
• Displacement: Is the distal fracture fragment
displaced compared with proximal fragment? To
what degree is the fracture displaced?
• Angulation: The angular deformity is defined in
degrees in terms of the distal fragment in relation to
the proximal fragment
Radiograph and Clinical Descriptions
• Shortening: Has the fracture caused shortening of
the involved bone?
• Rotation: Described both radiographically and
clinically
Radiograph and Clinical
Descriptions
• Fragmentation
– Multi-fragmentary fracture: several breaks in bone
creating 2 fragments
– Wedge fracture: either spiral (low energy) or bending
(high energy) and allow the proximal and distal fracture
fragments to contact each other
– Simple fractures: spiral, oblique or transverse
Radiograph and Clinical
Descriptions
• Soft tissue involvement:
– Is the fracture open or closed?
– Is associated neurologic or vascular injury present?
– Is there muscle damage or compartment syndrome?
Different Types of Fractures
Direction of the Fracture
Closed Fracture
• Fracture is not exposed to the environment
• All fractures have some degree of soft tissue injury
• Commonly classified according to the Tscherne
classification
Closed Fracture Classification
• Tscherne Classification:
– Grade 0: Minimal soft tissue injury; Indirect injury
– Grade 2: Direct injury; more extensive soft tissue
injury and severe bone injury
– Grade 3: Severe injury to soft tissue; degloving with
destruction of subcutaneous injury (Compartment
syndrome is a concern)
www.orthoinfo.aaos.org
Orthopedic Trauma Association
Open Fracture
• A break in the skin and underlying soft tissue leading
directing into or communicating with the fracture
and its hematoma
• Serious injury as infection can gain entrance into the
body through the wound and endanger limb or life
• Described by the Gustilo classification system
Orthopedic Trauma Association
www.jbjs.org
Classification of Open Fractures
• Type 1: Wound is smaller < 1 cm, clean and caused
by fracture fragment that pierces the skin (Low
energy injury)
• Type II: Wound > 1cm, not contaminated. And
without major soft tissue damage defect (Low energy
injury)
Classification of Open Fractures
• Type III: Wound > 1 cm, with significant soft tissue
disruption (High energy trauma)  severely unstable
fracture with varying degrees of fragmentation
• Type III fractures are subdivided:
– IIIA: Wound has sufficient soft tissue to cover the
bone without the need for local or distant flap
coverage
Classification of Open Fractures
• Type III fractures:
– IIIB: Disruption of soft tissue is extensive, such
that local or distant flap coverage is necessary
• Wound is often contaminated
– IIIC: Associated with an arterial injury that
requires repair
Epidemiology
• Frequency:
– Trauma is the leading cause of death ages 1-34 yrs
• Causes more years of lost productivity before age 65 than
coronary artery disease, cancer, and stroke combined
– Facture incidence is multi-factorial such as age, sex, comorbidities, lifestyle and occupation (In the US, 5.6 million
fractures/year)
Etiology of Fractures
• Occur when the force applied to a bone exceeds the
strength of the involved bone
• Both intrinsic + extrinsic factors are important
– Extrinsic factors: include the rate at which the bone’s
mechanical load is imposed and the duration, direction, and
magnitude of the forces acting on the bone
– Intrinsic factors: include the involved bone’s energy-absorbing
capacity, modulus of elasticity, fatigue, strength, and density
Etiology of Fractures
• Result of direct or indirect trauma
• Direct trauma consists of direct force applied to the bone
– Direct mechanisms include tapping fractures (eg, bumper
injury), penetrating fractures (eg, gunshot wound), and
crush fractures
• Indirect trauma involves forces acting at a distance from
the fracture site such as tension (traction), compressive,
and rotational force
Pathophysiology
• 5 phases of fracture healing:
– Fracture and inflammatory phase
– Granulation tissue formation
– Callus formation
– Lamellar bone deposition
– Remodeling
Fracture and Inflammatory Phase
• Actual fracture injuries to the bone include insult to the bone
marrow, periosteum, and local soft tissues
• The most important stage in fracture healing is the
inflammatory phase and subsequent hematoma formation
• It is during this stage that the cellular signaling mechanisms
work through chemotaxis and an inflammatory mechanism to
attract the cells necessary to initiate the healing response
Granulation Tissue Formation
• Within 7 days, the body forms granulation tissue
between the fracture fragments
– Various biochemical signaling substances are
involved in the formation of the granulation tissue
stage, which lasts approximately 2 weeks
Callus Formation
• During callus formation, cell proliferation and
differentiation begin to produce osteoblasts and
chondroblasts in the granulation tissue
– The osteoblasts and chondroblasts synthesize the
extracellular organic matrices of woven bone and cartilage,
and then the newly formed bone is mineralized
– This stage requires 4-16 weeks.
Lamellar bone Formation and
Remodeling
• During the fourth stage: Meshlike callus of woven
bone is replaced by lamellar bone, which is organized
parallel to the axis of the bone
• Final stage: remodeling of the bone at the site of the
healing fracture by various cellular types such as
osteoclasts
• The final 2 stages require 1-4 years
Patient Factors and Fracture Healing
Factors
Ideal
Problematic
Age, y
Youth
Advanced age (>40 y)
Comorbidities
None
Multiple medical
comorbidities (eg,
diabetes)
Medications
None
Nonsteroidal antiinflammatory drugs
(NSAIDs), corticosteroids
Social factors
Nonsmoker
Smoker
Nutrition
Well nourished
Poor nutrition
Fracture type
Closed fracture,
neurovascularly intact
Open fracture with poor
blood supply
Trauma
Single limb
Multiple traumatic injuries
Local factors
No infection
Local infection
Presentation of Single Limb Injury
• Obtain through hisotiry for the mechanism of injury
• Obtain history of any previous injury or fracture is
mandatory
• Obtain complete past medical and surgical history
– Including medications and allergies, as well as a social
(smoking and illicit drug use) and occupational history
Physical Examination in Single Limb Injury
• Physical exam must include a thorough inspection of
the integument (with documentation)
• If the fracture is open, a clinical photograph may be
taken for documentation purposes
• Distal neurologic and vascular status must be
assessed and documented
Physical Examination in Single Limb
Injury
• Palpate the entire limb including the joints above + below the
injury -- check for areas of pain, effusions, and crepitus
• Often, other associated injuries may be present (eg, injuries
to the spine with a jumping mechanism of injury)
• Assessment of range of motion (ROM) may not be possible,
but this should be documented
• Assessments for ligamentous injury and tendon rupture
Multiple Traumatic Injuries
• Initial assessment of a patient with polytrauma follows
the advanced trauma life support (ATLS) protocols
– Includes the identification and treatment of life-
threatening injuries
• The first step is evaluation of the individual's airway,
breathing, and circulation
– Immediate endotracheal intubation and rapid
administration of intravenous fluids may be necessary
Multiple Traumatic Injuries
• Spinal precautions must be maintained until injury to
the spine can be excluded clinically and
radiographically
– Radiographs or computed tomography [CT] scans
• Once patient is hemodynamically stable
– The secondary survey, a complete systems-based physical
examination, is performed
Initial Management of Fractures
• Consists of realignment of the broken limb segment
and then immobilizing the fractured extremity in a
splint
• Distal neurologic + vascular status must be clinically
assessed and documented before and after
realignment and splinting
Initial Management of Fractures
• If a patient sustains an open fracture, achieving hemostasis as
rapidly as possible at the injury site is essential
– This is achieved by placing a sterile pressure dressing over the injury
• Splinting is critical in providing symptomatic relief for the patient,
preventing potential neurologic + vascular injury and further injury
to the local soft tissues
• Patients should receive adequate analgesics in the form of
acetaminophen or opiates, if necessary.
Management of Open Fractures
• Treatment goals for open fractures are to:
– Prevent infection, to allow the fracture to heal, and to
restore function in the injured limb
• Once initial assessment, evaluation, and management of
any life-threatening injuries are complete, the open
fracture is treated
• Hemostasis should be obtained, followed by antibiotic
administration and tetanus vaccination
Management of Open Fractures
• Cefazolin or clindamycin is adequate for type I + type II
fractures
• Aminoglycoside (eg, gentamicin) can be added for a
severely contaminated wound (type III)
• If injury is a "barnyard injury" or water-type injury,
penicillin should also be added to provide prophylaxis
against Clostridium perfringens
Management of Open Fractures
• Urgent irrigation and debridement (I&D) of the wound in
the operating room is mandatory
– For type II and type III injuries, serial I&Ds are
recommended every 24-48 hours after the initial
debridement until a clean surgical wound is ensured
– The wound is closed when it is clean and antibiotics are
generally continued until 2 days after the final I&D
Management of Open Fractures
• Management of the open fracture depends on the
site of injury and type of open fracture
– Wound is subsequently stabilized either temporarily or
definitively
• If soft-tissue coverage over the injury is inadequate
– Soft-tissue transfers or free flaps are performed when the
wound is clean and the fracture is definitively treated
Fracture Management
• Divided into non-operative and operative techniques
– Non-operative technique: consists of closed reduction
if required  followed by a period of immobilization
with casting or splinting
– Closed reduction is needed if the fracture is
significantly displaced or angulated
• If the fracture cannot be reduced, surgical intervention
may be required
Fracture Management – Surgical
Indications
• Failed nonoperative (closed) management
• Unstable fractures that can’t be maintained in a reduced
position
• Displaced intra-articular fractures (>2 mm)
• Fractures that are known to heal poorly following non-
operative management (eg, femoral neck fractures)
Fracture Management – Surgical
Indications
• Large avulsion fractures that disrupt the muscle-tendon
or ligamentous function of an affected joint
– Example patella fracture
• Impending pathologic fractures
• Multiple traumatic injuries involving pelvis, femur, or
vertebrae
• Unstable open fractures or complicated open fractures
Fracture Management – Surgical
Indications
• Individuals who are poor candidates for non-operative
management that requires prolonged immobilization
– Example: elderly patients with proximal femur fractures
• Fractures in skeletally immature individuals that have
increased risk for growth arrest
– Example: Salter-Harris types III-V)
• Nonunions or malunions that have failed to respond to
non-operative treatment
Contraindications
• Active infection (local or systemic) or osteomyelitis
• Soft tissues that compromise the overlying fracture or
the surgical approach
• Medical conditions that contraindicate surgery or
anesthesia
– Example: recent myocardial infarction
• Cases in which amputation would better serve the limb
and the patient
Any Questions??
References
• Buckley, R. General Principles of Fracture
Care. Medscape Jan 2010.
• Orthopedic Trauma Association. www.ota.org