Fractures may be classified according to:
[oblique, spiral, transverse, segmental, or comminuted]
[displacement of distal fragment, angulation, anticular involvement]
[proximal, middle or distal]
[dislocation, open fractures etc.]
The cause/mechanism of injury needs, if possible to be known. This provides clues to the personality of the fracture and the treatment.
For example:
- compression forces result in angulated or T.Type fractures
- rotational forces result in spiral fractures
- traction injuries result in avulsion fractures
Detailed information is provided in other texts. The information has been channelled into specific sections and presented under these relevant headings.
1) Open Fractures
2) Life Threatening Situations
3) Orthopaedic Procedures
4) Orthopaedic Complications
5) Soft Tissue Trauma
6) Principles of Internal Fixation
OPEN FRACTURES
Significant Points
- Open fractures must be handled with extreme care and clinical skills as contamination and soft tissue disruption may quickly become serious.
- Formal, thorough debridement and irrigation should be given, within eight hours of the injury. Otherwise serious infection may result.
- Antibiotics [iv] consisting of a first or second generation cephalosporin and an aminoglycoside should be given for 48 hours. Appropriate immobilisation and fixation is also necessary.
- The clinical classification of Open Fractures is based on the size of the wound and the amount of soft tissue injury.
- Gunshot wounds are the case of most Open Fractures. The resultant soft tissue disturbance, also the bone destruction is usually based on the velocity of the bullet. For instance the relative low velocity of hand guns, causes the least soft tissue destruction. Treatment usually consists of entry / exit wound debridement. The high velocity of military rifles, etc. causes massive soft tissue destruction which requires stage II debridement of the entire missile track.
In either case any intra-articular bullets need to be removed to avoid lead intoxication.
If there is arterial injury there will be a decreased [sometime absent] pulse, an expanding haematoma plus massive blood loss. In such cases arteriograms must of course be used sparingly.
LIFE THREATENING SITUATIONS
- A.T.L.S. guideline must be slightly followed. Where these guidelines are applied preventable death has decreased markedly - from 14% to 3%. Concept of the Golden Hour.
- The causes of ADULT TRAUMA include gunshot wounds, road/traffic accidents, stabbings, industrial accidents also sport, recreational and domestic accidents.
- In cases of life-threatening TRAUMA the patient must first be stabilised ‘Life before limb’ must always be the first principle of treatment.
This includes:
- prevention of ASPHYXIA by restoring or maintaining an unblocked airway.
[ Nasotracheal intubation is recommended for breathing patients - particularly if cervical spine injury is apparent].
[Oral endotracheal intubation with in-line traction is recommended for non breathing patients].
- the stopping of serious blood flow.
[if there is haemorrhaging - often the result of a ruptured viscera - the positioning of suprapubic tubes, plus incisions and / or colostomies may be required].
[if there is severe haematuria, intravenous pyelography may be required].
- thorough treatment of shock - a careful check of possible injuries to heart or lungs. - if necessary a laparotomy to discover abdominal injuries [the most common are liver or spleen] or a craniotomy to establish the severity and type of any head injury/ies.
- thorough assessment of the accompanying bone trauma as soon as the patient is stabilised.
ORTHOPAEDIC PROCEDURES
A brief description of each procedure which is listed below, is given in ensuing texts.
- Radiography and Other Forms of Imaging
- Reduction Procedures
- Immobilisation Procedures
- Ensuring Preservation of Function
Plus a Summary.
A] Radiation and Other Forms of Imaging
Imaging is most necessary in assessing the extent of injury/injuries. Orthopaedists need to clear definition of the damage to both bone and soft tissue as a guide to prescribing relevant treatment.
Relevant Points
- Orthopaedists should ensure that standard AP and lateral radiographs include both the joint above and the joint below the given fracture.
- Special traction radiographs are recommended for comminuted or severely displaced fractures.
- If there are peri-articular fractures, oblique views of the internal and external condition would give additional detail.
- Tomograms [producing a cross section ‘slice’] are most helpful in final evaluation, particularly of sternoclavicular injuries, tarsal and carpal fractures, also tibial plateau fractures.
- Magnetic Resonance Imaging [M.R.I.] is a diagnostic technique which provides cross sectional; also 3 dimensional images of injuries. [In this process Magnetic Field reactions are used not x-rays or radiation]. M.R.I. presents a very clearly defined picture of the complete injury/ries. Soft tissue damage is ‘picked up’ particularly well.
- C.T. [Computer Tomography] Scans are useful in evaluating the extent of most injuries most particularly complex spinal, pelvic and calcaneal injuries. As with M.R.I. it has the advantage of minimising radiation exposure.
- Nuclear Medicine is becoming increasingly useful in ‘finding’ the obvious injuries such as stress fractures and subtle wrist complaints.
Radiographs, combined with other forms of imaging can help ascertain common patterns in specific injuries, also in particular areas of the body. B] Reduction Procedures
This can involve either internal fixation [open] or manipulation and/or traction. [closed]. Joint surface involvement demands near-an-atomic reduction [< 2mm]. The age and physiologic stability of the wound and also the patient plus the usual function of the damaged area must all be considered carefully if planning Reduction. C] Immobilisation Procedures
Immobilisation is used to:
- decrease movement at the fracture site
- prevent angulation and/or displacement
- relieve pain
Immobilisation can be achieved by:
- traction
- internal and / or external fixation
- splinting
- casting
- orthotics
D] Ensuring Preservation of Function
Planned, directed REHABILITATION is essential during and after all severe trauma treatment. Patient require emotional support and encouragement in addition to specific, symptomatic physical and occupational therapy. For example if lower extremity intra-articular fractures are suffered, the patient should be kept non weight-bearing while encouraged to engage in a range of motion at an early stage of healing. Summary
Orthopaedists will achieve the best results for their patients if they manage:
- absence of, or limited infections
- minimal necrosis
- immobilisation
- the presence of physiologic stress
- an adequate vascular supply
- sufficient emotional, environmental and resource support.
ORTHOPAEDIC COMPLICATIONS
Introduction
Orthopaedic complications can be a direct result of the injury [intrinsic] or they can be associate with other organ systems [intrinsic]. Information concerning general complications is given in ensuing texts. These include:
- Bone Healing Abnormalities
- Infection
- Soft Tissue Injuries
- Pulmonary Complications
- Bleeding Disorders
- G.I. Complications
- Reflex Sympathetic Dystrophy
- Late Complications
• BONE HEALING ABNORMALITIES This encompasses
- delayed union
- nonunion
- avascular necrosis
These complications occur more frequently in bones with limited healing potential due to the limited/disturbed blood supply.
I. Delayed Union
This term refers to fractures which continue to allow free movement of bone ends more than 4 months after the injury and the beginning of treatment.Delayed Union can be caused by:
- infection
- inadequate fixation
- inadequate blood supply
- excessive space between fracture fragments
- too much or too little motion at the fracture site
- soft tissue interposition
II. Nonunion
This term refers to those fractures which still allow free movement of bone ends more than 6 months after the injury and the start of treatment. Nonunions are classified as being hypervascular [hypertrophic] or avascular [atrophic] based on their biologic reaction. Treatment includes:
- injection of bone marrow or other osteogenic materials
- more secure internal fixation
- surgical incision of intervening tissue
- allowing compression at the fracture site
- bone grafting
- electrical stimulation
- prosthetic replacement
III. Malunion
This term refers to fractures which heal [forge a union] in a clinically imperfect position. Though sometimes caused by lack of orthopaedic care, it is on occasions, unavoidable. Malunion will mostly cause shortening with an overlap. Treatment is directed at correcting the anatomic abnormality. [N.B. shortening can also result from bone loss or growth plate injuries]. IV. Avcascular Necrosis - Bone Death
This malady is most common with intra-articular fractures especially of the femoral head/neck, femoral condyles, proximal scaphoid, talar neck and proximal humerus. The main cause is disruption of the blood supply. Avascular Necrosis causes nonunion and can lead to osteoarthritis and also collapse. In advanced cases excision of the avascular fragment, arthroplasty or arthrodesis may be required. Further information is given in the Basic Sciences Section under the heading ‘Osteonecrosis’.
• INFECTION
Most commonly this is a complication of Open Fractures. [immediate and adequate debridement of all open fractures is essential - both initially, and again if infection becomes apparent.] Additional care is needed if ‘fight bites’ are obvious also the bites of cats or dogs.
The first symptoms of INFECTION are persistent pain, stiffness and progressive, concentric joint space narrowing.
The disorders caused by infection result in severe suffering and systemic disturbance. Some are life threatening. Any list of the major disorders will include: 1. TETANUS caused by an organism [clostridium tetani] which flourishes in dead tissue. It produces an exotoxin which passes to the central nervous system. Tetanus is usually avoided by early toxoid boosters coupled with extreme care. Once established it causes contractions to the jaw and face muscles plus those near the affected area. Ultimately it affects the diaphragm and intercostal muscles; eventually leading to death by asphyxia, if unattended.
Treatment includes:
- intravenous antitoxin
- heavy sedation with a muscle relaxant
- tracheal intubation, if necessary.
2. GAS GANGRENE caused by a clostridium species or, in rare cases, a G. [strep] infection. Very severe symptoms present within 24 hours of infection. They include:
- a foul smelling, scrosanguineous brown discharge
- oedema
- progressive pain
- ultimate toxaemia and coma of the patient.
It is a life threatening conditions.
The treatment includes:
- a high dosage of penicillin G and clindamycin
- hyperbaric oxygen
- amputation, if advanced
3. TOXIC SHOCK SYNDROME caused by gram-positive bacteria superinfection results from toxaemia not septicemia. The symptoms are usually severe, including:
- fever
- hypotension
- an erythematous macular rash
- systemic disturbances
- a serious exudate [with G plus cocci].
Treatment requires I. and D as soon as possible plus antibiotics IV. Emergent fluid resuscitation may also be necessary. 4. NECROTIZING FASCIITIS is an aggressive, life threatening fascial infection, sometimes associated with an underlying vascular disease such as Diabetes. It is often associated with strep gangrene also and may be polymicrobial with both aerobes and anaerobes.
Treatment requires wide surgical I. and D. plus antibiotics IV, as soon as possible.
5. ACUTE OSTEOMYELITIS [which can quickly degenerate to chronic osteomyelitis] is most common in the metaphyses or epiphyses of the long bones. Staph. aureus is the most common offender.
Symptoms include:
- pain
- loss of function
- sometimes the developing of a soft tissue abscess
Clinical Occurrences include:
- soft tissue swelling
- demineralisation
- sequestra
- in the latter stages, involucrum.
Treatment follows a process of:
- identification of the organism
- selection and delivery of appropriate antibiotics to the site of the infection
- halting tissue destruction
SOFT TISSUE INJURIES This includes direct injuries to nerves, vessels and soft tissue as well as indirect compromise of these tissues. [ The function of specific soft tissue, sections will of course, have a bearing on the injury outcome].
Injuries can be classified as:
These are rare but the consequences are usually severe. The most common injuries occur with shoulder dislocations, severe knee injuries/dislocations, and supracondylar elbow fractures . Repair, if necessary, should be within 6 hours of the injury, if possible. Fasciotomy may be necessary.
This relatively uncommon. Most injuries are neuropraxias from stretch and more than 70% heal within 6 weeks.
Information on Repair, if necessary, is provided in the Basic Sciences Section.
Increased pressure can lead to serious sequelae. Risk is further increased with extended use of antishock garments. Compartment Syndrome is most common following serious injury to the forearm and / or leg.
Symptoms include:
- pain
- followed by pallor, paraesthesia, paralysis
- pulselessness
Treatment includes:
- fasciotomy within 48 hours to prevent muscle necrosis
- utilisation of skin incisions
- concomitant muscle debridement for any ischaemic muscle lacking the capacity to bleed, contract, etc.
PULMONARY COMPLICATIONS There are three main categories.
This thromboembolic disease is the most common pulmonary complication. It usually requires the use of intermittent pneumatic compression, and low-molecular-weight heparin warfarin.
- Adult Respiratory Distress Syndrome A.R.D.S. can be direct [affecting breathing] or indirect [caused by shock or sepsis.] It is characterised by pulmonary oedema and decreased function and becomes worse by prolonged hyporolemia nad decreased left ventricular function. A.B.G. measurements are best for diagnosing A.R.D.S. and ventilation with P.E.E.P. needs to be given as therapy.
This is a form of A.R.D.S. which usually follows cases of multiple fractures, mostly the long bones. It results in changes in chylomicron stability and conversion to free fatty acids in the lung parenchyma. Symptoms present within 72 hours after injury resulting in tachycardia, hyperthermia, tachypnoea and hypoxea plus a mental state change in the patient.
Treatment includes
- stabilisation of the injured bone [the earlier the better]
- pulmonary support
- steroids may assist
BLEEDING DISORDERS Excessive bleeding can cause hypovolemic shock and disseminated intravascular coagulation. [shock is the manifestation of decreased blood flow to the tissues].
It causes:
- pale, cool extremities
- oliguria
- tachycardia
Diagnoses of D.I.C. involves recognition of decreased antithrombin III and fibrinogen plus increased values of PT/PTT and fibrin split products.
General treatment includes
- immediate whole blood
- I.V. fluids
- dextran solutions
Addition treatment should be directed towards the individual underlying cause studied, guarded use should be made of heparin, platelets and DDAVP.DIC as excessive anticoagulation can lead to bleeding into the soft tissues.
Albumin should be avoided. If Thrombotic Thrombocytopenic occurs it should be treated with I.V. steroids. G.I. COMPLICATIONS These can be the result of the trauma itself or a late complication.
The complications include:
which can be treated with appropriate antacids and H2 blockers.
resulting from compression of the 2nd portion of the duodenum by the superior mesenteric artery. It results in postoperative small bowel obstruction and severe projectile vomiting.
Cast Syndrome usually occurs after placing spine fractures in plaster.
Treatment includes removing the constrictive device and the nasogastric tube.
REFLEX SYMPATHETIC DYSTROPHY
This disorder follows either trauma or surgery for local, systemic disease.
It is initially characterised by:
- pain
- swelling
- discolouration
- stiffness of the affected extremity
If the cause [vasomotor dysfunction of the sympathetic nervous system] worsens so too do the symptoms, with the patient exhibiting:
- a ‘vicious cycle’ of pain
- obvious tissue reaction
- extreme oedema
- immobility
- vasospasm
Treatment includes P.T. in the early stages, then N.S.A.I.Ds, psychological aids and a sympathetic blockade to interrupt the cycle. A sympathetic blockage is obtained with a long-acting anaesthetic injection of the sympathetic ganglia upper extremity or an epidural injection for the lower extremity. Orthopaedists need to take great care in their prognosis of R.S.D. disorders.
LATE COMPLICATIONS
This can be either systemic or involve local soft tissue, bones and/or joints.
Such complications include:
Which follow injuries with large haematomas. Sometimes late excision [up to 6 months after the injury] is required.
- Post Traumatic Osteoarthritis
Commonly follows intra-articular fractures, not anatomically reduced. Treatment includes systematic, Adult Reconstruction.
- Immobilisation Hypercalcemia
Is a rare disorder. It often occurs after acetabular fracture repairs and is most common in patients with Paget’s disease.
The most common of the varied symptoms are:
- nausea / vomiting
- severe abdominal pain
- acute personality changes
Treatment could include Indomethacin and Irradiation which appear to decrease the H.O.
SOFT TISSUE TRAUMA
Soft tissue trauma can be severe and life threatening. The injury/injuries can be sustained in conjunction with bone trauma or after it, while the patient is incapacitated. Soft Tissue Traumas include:
- THERMAL INJURIES which encompass,
- freezing injuries - burns
- electrical shocks / burns
- chemical burns
- chemotherapeutic extravasation
Symptomatic treatment is needed as soon as possible, to restore normal function if possible, and to avoid infection. Severe damage, particularly with electrical injuries can result in amputation. - HIGH PRESSURE INJECTION INJURIES
These occur from accidental injections usually by paint or grease guns. Paint injections lead to tissue necrosis and grease injections, to fibrosis. Treatment includes antibiotics IV thorough I and D plus steroids.
This can cause extensive soft tissue destruction often leading to Compartment Syndrome. Careful administration of antibiotics and anti-venom serum is necessary. Fasciotomies may also be needed. PRINCIPLES OF INTERNAL FIXATION The following fixation devices are commonly used. Before use, pre-operative planning is imperative. A thorough knowledge of the local anatomy, the mechanical demands and the injury characteristics is essential. Addition information on the devices listed below is given in the ensuring text.
Fixation Devices
- lag screws - compression plates
- reconstruction plates
- Special Devices including
- sliding hip screws - sliding condylar screws - cannulated screws • PLATES and SCREWS These are often used in conjunction with compression plating and form the basis for AO technique. They allow compression of the fracture surface by overdrilling the proximal cortex.
These are used on the tension side of transverse or short oblique fractures. They provide stability and act as a load sharing device.
The sequence of screw placement in the contoured plate holes, is as follows:
- a neutral guide, to attach plate
an offset guide, to compress the fracture an offset guide, to further compress the fracture after screw 2 is loosened. at least 3 screws placed with the neutral guide plus an inter fragmentary screw in a different plane.
Six or more cortices are needed on each side of a forearm fracture and at least 8 cortices are needed for fixation of lower extremity and humerus fractures. Plates are usually left in place [but can be removed if there is a need] for up to 2 years.
These are used mainly for pelvic and distal humerus fractures. They are more pliable and allow positioning for use as a neutralisation plate. • INTRAMEDULLARY FIXATION This is a commonly used and successful method of fixation for lower extremity diaphyseal fractures:
Advantages include:
- earlier ability to weight bearing
- it can be placed in a closed position
- proper axial alignment
Disadvantages include:
- the canal diameter can limit the size of the nail
- there is less rotational control [but this can be improved with interlocking nails].
- it is sometimes technically difficult
- there is disruption of the endosteal blood supply
Orthopaedists should wait at least one year before removal.
• EXTERNAL FIXATION
This is used mainly in the management of Grade III open fractures which have a high risk of infection. The Orthopaedist maintain access to the wound while stabilising the fracture. It is used specifically in helping stabilise anterior disruptions of the pelvis, in spacing of areas wit segmental bone loss and in comminuted distal radius fractures.
• SPECIAL DEVICES
There is an ever-increasing amount. The most commonly used include:
This is a load sharing device which allows screw insertion to be placed at variable angles.
These are used in the fixation of a variety of fractures most especially femoral neck fractures. It is advisable to have a placement of K-wires prior to the insertion of the larger screws to lessen the risk of iatrogenic neurovascular injury.
These can be used proximally for unstable subtrochanteric fractures but are most effective for distal femur fractures - with less than 9cm proximal to the joint.
• TENSION BAND WIRING This technique allows fixation on the tension side, relying on motion to allow union on the compression side. Parallel K-wires need to be placed close to the outer cortex to take advantage of this design with additional wire placed under the K-wires before being tightened.
Tension Band Wiring is used most often for the fixation of patella, ankle and olecranon fractures.
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