Overview of trauma management and fracture healing/classification/management

1. Orthopaedic Trauma
Mr Hiren Divecha
ST3 T&O
19/1/2011

3. Definitions

4. Trauma & Basic Management

5. Trauma
• Golden Hour of Trauma
– Rapid transport of a severely injured patient to a
trauma center for definitive care
– Initial treatment has a significantly higher chance
for survival during this period

7. Trauma Evaluation
• ATLS
– Advanced Trauma and Life Support
– A standardized protocol for the evaluation and
treatment of victims of trauma
– Developed by a Nebraska orthopaedic surgeon
who was involved in a trauma and was not
satisfied with the lack of a protocol for such
patients

8. ATLS
• Airway (+ cervical spine
immobilisation)
• Breathing (+ high flow O2)
• Circulation
• Disability
• Exposure

9. Primary Survey
• Rapid assessment of ABC’s and addressing life
threatening problems
– establishing airway and ventilation, placing chest tubes,
control active hemorrhage
• Place large bore IV’s and begin fluid replacement for
patients in shock
• Trauma x-rays
– chest, pelvis and lateral C-Spine

10. Secondary Survey
• Assessing entire patient for
other non-life threatening
injuries.
• Orthopaedic assessment of
skeleton
– splint fractures
– reduce dislocations
– evaluate distal pulses and
peripheral nerve function
• Obtain Xray or CT of
affected areas when pt is
stable

11. Trauma Assessment
• History  Mechanism of Injury
• Palpation
• Note swelling, Lacerations
• Painful ROM
• Crepitus- that grating feeling
when two bone ends rub against
each other
• Abnormal Motion- ie the tibia
bends in the middle
• Check pulses, sensory exam, and
motor testing if possible

12. • Assess for lacerations that communicate with
the fracture
– Closed Fracture= intact skin over fracture
– Open Fracture= laceration communicating with
fracture (often referred to as a compound fracture
by lay persons)

13. Emergency Skeletal Issues
• Hemorrhage control from Pelvis Fractures in pt with
labile blood pressure (shock)
– Close pelvic volume
• Hemorrhage control from open fractures
– Direct pressure
• Restore pulses by realigning fractures and
dislocations

14. Urgent Skeletal Issues
• Irrigation and Debridement of open fractures
• Reduction of dislocations
• Splinting of fractures
• Compartment syndromes

15. Fracture Basics

16. Basic Biomechanics
• Bending
• Axial Loading
– Tension
– Compression
• Torsion
Bending Compression Torsion

17. Describing The Fracture
• Mechanism of injury
– traumatic, pathological, stress
• Anatomical site
– bone and location in bone
• Fracture geometry/ type
• Displacement
– three planes of angulation
– translation
– shortening
– rotation
• Articular involvement
– Involving joint
– Fracture – dislocation
• Soft tissue injury
– Closed vs open
– nerves, vessels, tendons, tissue loss

18. Fracture Mechanics

20. Reading X-rays
• Say what it is
– what anatomic structure are you looking at and
how many different views are there
• Regional Location
– Epiphysis, metaphysis
– Diaphysis (rule of 1/3rds)
– Intra/extra-articular
• Fracture geometry/ type
– Transverse, Oblique, Spiral

21. Reading X-rays
• Condition of the bone
– Comminution (3 or more parts)
– Segmental (middle fragment)
– Butterfly segment
• Deformity
– Angulation (varus/valgus, anterior/posterior)
– Translation
– Rotation
– Shortening/ distraction

22. Fracture Pattern
• Transverse
• Produced by a
distracting or tensile
force

23. Fracture Pattern
• Spiral
• Produced by a twisting/
torsional force

24. Fracture Pattern
• Butterfly
• Produced by pure
bending force

25. Fracture Pattern
• Comminuted
• Multifragmentary
• High energy transfer!!

26. Location-Diaphysis
• Shaft portion of bone

27. Location-Metaphysis
• The ends of the bone (if
the fracture goes into a
joint it is described as
intra- articular)

28. What do you see?

29. What do you see?

30. What do you see?

31. What do you see?

32. Fracture Management

33. Goals of fracture treatment
• Restore patient to optimal functional state
• Prevent fracture and soft tissue complications
• Get fracture to heal and in satisfactory position for optimal
functional recovery
• Rehabilitate as early as possible

34. Inflammatory/ Hematoma Phase (1st)
• Up to 1 week
• Acute inflammation
• Hematoma formation
(48-72 hours)
• Inflammatory cytokines
• Fibroblasts –
granulation tissue
• Angiogenesis

35. Soft Callus Phase(2nd)
• 1 week – 1 month
• Chondroblasts +
fibroblasts
• Fibrous tissue +
cartilage + woven bone

36. Hard Callus Phase (3rd)
• 1 – 4 months
• Soft callus resorbed and
replaced by osteoid
from osteoblasts
• Osteoid mineralised
(hydroxyapatite)
• United, solid, pain free

37. Remodeling Phase (4th)
• Up to several years
• Hard callus remodels to
woven bone then
lamellar bone
• Osteoclasts/ osteoblasts
• Medullary canal reforms
• Remodels according to
stresses/ loading
– Wolff’s Law (1892)

38. Factors affecting fracture healing
• Energy transfer of the injury
• The tissue response
– Two bone ends in apposition or compressed
– Micro-movement or no movement
– Blood supply
– Infection
• The patient
• The method of treatment

40. Diagnosing the bone injury
• History
– Mechanism
– If pain preceded trauma ?pathological
• Examination
– General - ABCDE
– Local – the fracture, swelling, tenderness (crepitus?), abnormal posture,
skin wound
– Distal –
• Circulation – vascular injury?
• Neurological – sensory and motor deficit?
• Investigation - Imaging
– 2 Views (AP/Lateral)
– 2 Joints (above and below injury)
– 2 Sides (for comparison, mainly in children)
– 2 Times (before and after treatment)

41. Treatment of fractures
• Reduce
• Maintain reduction (+ hold until union)
• Rehabilitate – restore function
• Prevent or treat complications

42. Maintain reduction
• How?
– External method
• POP (+ equivalents), traction, external fixator
– Internal method
• Wires, pins, plates, nails, screws

43. Maintain reduction – external method
• POP
• Mould with palms
– Adv – cheap,easy to use,
convenient, can be
moulded
– Disadv – susceptibility to
damage (disintegrates
when wet), up to 48hrs
to dry

44. Maintain reduction – external method
• Resin cast
• Adv
– lighter and stronger
– sets in 5-10mins
– max strength in 30mins
• Disadv
– Cost
– more difficult to apply/remove
– more rigid with greater risk of
complications eg. swelling and
pressure necrosis

45. Maintain reduction – external method
• Skin traction
– Temporary measure
when operative
fixation not available
for awhile
– Skin can be injured if
applied for long
periods of time

46. Maintain reduction – external method
• Skeletal traction
– Requires invasive
procedure for longer
term traction requiring
heavier weights
– Complications
associated with pin
insertion eg. infection

47. Maintain reduction – external method
• External fixator
• Indications
– Fractures associated with
severe soft tissue
– Fracture associated with N/V
damage
– Severely comminuted and
unstable fracture
– Unstable pelvic fracture
– Infected fracture
• Complications
– Pin track infection
– Delayed union

48. Maintain reduction – internal method
• Advantages
– Shorter hospital stay
– Enables individuals to return to fxn earlier
– Reduces incidence of non and mal-union
• Indications
– Fractures that need operative fixation
– Inherently unstable fractures prone to re-displacement after reduction
(eg. mid-shaft femoral fractures)
– Pathological fracture
– Polytrauma (minimise ARDS)
– Patients with nursing difficulties (paraplegics, v. elderly, multiple
trauma)

49. Maintain reduction – internal method
• Stainless steel, titanium, cobalt
• Complications
– Infection
– Non-union
– Implant failure
– Re-fracture

50. Maintain reduction – internal method
• Wires
– Can be used in conjunction
with other forms of internal
fixation
– Used to treat fractures of
small bones

51. Maintain reduction – internal method
• Pins
– Usually used in pieces of
bone that are too small to be
fixed with screws
– Usually removed after a
certain period of time, but
may be left in permanently
for some fractures

52. Maintain reduction – internal method
• Plates
– Extend along the bone and
screwed in place
– May be left in place or
removed (in selected cases)
after healing is complete

53. Maintain reduction – internal method
• Nail or rods
– Held in place by screws until
the fracture is healed
– May be left in the bone after
healing is completed

54. Maintain reduction – internal method
• Screws
– Most commonly used implant
– Can be used alone to hold a
fracture, as well as with
plates, nails or rods
– May be designed for a
specific fracture
– May be left in place or
removed after the bone heals

55. Maintain reduction – how long?
• Judge each case on its own merits
• X-ray in POP for position; out of POP to clinically assess state
of healing
• Sticky – “Deformable but not displaceable”
• Union (weeks)
– Incomplete repair; Part moves as one; Local tenderness; Local pain on
stress; See fracture line on-x-ray
• Consolidation (months)
– Complete repair; No external protection needed; Upper limb 6/52;
Lower limb 12/52; Half for child; Double for transverse fractures

56. Complications of fractures
• Early • Late
– Visceral/ vascular/ nerve injury – Mal-union
– Haemarthrosis – Delayed union
– Infection – Non-union
– Fat embolism – Tendon rupture
– Compartment syndrome – Myositis ossificans
– Osteonecrosis
– Complex regional pain syndrome
– Osteoarthritis and joint stiffness

57. Thanks for listening !
Any questions