2. HISTORY
⢠1) AGE-
⢠Epiphyseal separation â children
⢠Greenstick # - children
⢠Dislocation - adult
⢠Fractures - at any age
⢠2) THE AMOUNT AND NATURE OF VIOLENCE
⢠How did it occur ??
⢠Mechanism of force ??
4. ⢠How forceful was the injury ??
⢠* pathological #-violence is not severe enough to cause #
femoral neck #- senile osteoporosis
subtrochanteric #- pagets dz
femoral shaft # - 2ndary carcinoma
5. ⢠Nature of violence âdirect
⢠a) tapping in nature-transverse #
⢠b) crushing â communuted #
⢠-indirect
⢠a) twisting â spiral #
⢠b) bending force-transverse/ oblique #
⢠c)bending +axial compression-butterfly fragment
⢠d)twisting+angulation+axial compression-short oblique #
⢠- muscular
6.
7. ⢠Muscle contracts against resistance may lead to #
⢠Ex- patella,olecranon ,lesser trochanter of the femur
⢠3) PAIN- in # pain is felt only during movement of # site
⢠Pain -least in impacted and greenstick #
⢠-unbearable and constant in dislocation
⢠4) LOSS OF FUNCTION-
⢠Unable to move the fractured limb
⢠He cannt put weight on it
⢠In Dislocation âunable to move the joint even slightly
8. ⢠5)DEFORMITY OR SWELLING
⢠# and dislocation often presents with swelling or deformity
10. INSPECTION
⢠1)ABNORMAL SWELLING AND DEFORMITY-
⢠Deformity- is due to displaced # fragments
⢠Swelling- is dt hematoma
⢠2) ATTITUDE-
⢠In certain # patients adopt particular attitude
⢠# NOF â limb externaly rotated
⢠Posterior dislocation of hip- thigh is in flexion ,adduction and internal
rotation
11. ⢠3)SHORTENING-
⢠Dt overlapping of fracture fragments
⢠4) OVERLYING SKIN-
⢠Skin intact or not???
⢠Intact- closed #
⢠Not intact -# hematoma communicating to outside-Open#
⢠Edema ,bullae,blebs are quite common dt interference with venous
return
⢠Echymosis also appears within a few days after a # or dislocation
12. PALPATION
⢠1)TENDERNESS-
⢠Local bony tenderness is valuable sign of #
⢠Elicited with relation with bone not with the soft tissue
⢠All throughout the length bone is palpated
13. ⢠2)BONY IRREGULARITY-
⢠Whole bone is palpated
⢠To look for any irregularity-such as sharp elevation,gap etc.
⢠Definite sign of #
⢠3) ABNORMAL MOVEMENT-
⢠This is also definite sign of #
⢠Can be elicited by moving one fragment against other
14. ⢠4) CREPITUS-
⢠It is a sensation of grating which may be felt or heard ,when the bone
ends are move against each other
⢠Other condition which produce crepitus-
⢠Ex Hematoma,surgical emphysema,gas gangrene,oa ,tenosynovitis
and charcots joint
15. ⢠5) PAIN ELICITED BY MANIPULATING FROM DISTANCE-
⢠a) by rotating â in case of humerus or femur
⢠b) by squeezing-both bones of leg and forearm
⢠c ) by axial pressure in the line of bone-in metacarpal and metatarsal
#
⢠6) ABSENCE OF TRANSMITTED MOVEMENTS-
⢠Assessed by rotating humerus and femur with flexed elbow or knee
respectively by palpating the tubercle of humerus or trochanter of
the femur
16. ⢠7) SWELLING-
⢠Characteristic should be noted -wheather bony swelling swelling
arises from neighbouring joint ??
17. MEASUREMENT
⢠1)LONGITUDINAL-
⢠To know if there is any shortening
⢠2)CIRCUMFERENTIAL-
⢠To now if there is any wasting dt injury
* While taking measurement the sound limb should be kept in the
same position as the affected limb
* Always good to measure the healthy limb first
* measurement should be marked with skin pencil before the use of
measuring tape
20. * Measurement should be at the same level in both the limbs in case of
circumferencial measurement
21. MOVEMENTS
⢠Both active and passive movement should be tested
⢠Good â no bony or joint injury
⢠Stiffness of the joint is a complication of the # and may be dt-
intraarticular and periarticular adhesions,myositits
ossification,sudecks osteodystrophy
22. INVESTIGATIONS
⢠A) X RAYS-
⢠minimum 2 view
⢠Ap /lateral
⢠Some time oblique and other special views
⢠B)CT SCAN â
⢠C)MRI-too expensive
24. GOAL OF FRACTURE M/M
⢠Restore the anatomy back to its normal or as near to normal as
possible
⢠There should not be any functional disability to the pt following the
treatment of fractures
25. MANGEMENT OF SIMPLE FRACTURES
⢠can be managed with conservative or operative methods
⢠A) CONSERVATIVE METHODS
⢠For undisplaced #,incomplete #,impacted #
⢠Cuff and collar sling- for upper limb #
⢠Strapping for # clavicle,finger #,toe #
⢠Pop slab
⢠NSAIDS
28. ⢠B)OPERATIVE â
⢠For displaced #
⢠CLOSED REDUCTION OR OPEN REDUCTION
⢠1)Closed reduction-
⢠Adopted usually for simple frctures
⢠Technique followed is traction and counter traction method
⢠Continous traction is used for reduction of fracture
⢠Ex gallows traction for # sof in children,skeletal traction for adult SOF
31. ⢠Once the # is reduce it has to be retained in position till # unites by
pop,continuous traction ,or by using functional brace
⢠Rehabilation is by physiotherapy and exercises once the fracture
unitess
⢠2)Open reduction
⢠Indiacated once the conservative m/m fail or when there are specific
indication
32. ⢠INDICATIONS-
⢠Absolute- failed closed reduction
- displaced intraarticular #
-type 3 and 4 epiphyseal injury
- major avulsion#
- nonunion
⢠Relative -multiple # - for better nursing care
-delayed union - to avoid prolong bed rest
- loss of reduction
33. ⢠METHODS OF OPEN REDUCTION-
⢠After the exposure the # is redued by direct or
⢠indirect methods the # is reduced without exposing by positioning
and traction over the fracture table s,skeletal traction etc
⢠PRINCIPLES OF OPEN REDUCTION( by lambotte )
⢠Exposure-the # is adequately exposed through a proper approach
⢠Reduction of # fragments under direct vision
⢠Temporary stabilization-of the # using k wire done first if necessary
34. ⢠Definitive stabilization using palte ,screws or intramedullary nails ,k
wire ,ss wire etc done later,
⢠Rehabilation process is same as closed mm of fractures
⢠CONTRAINDICATION OF OR-
- Infection
-small fragments
- soft tissue damage
- poor general and medical condition
35.
36. OPEN FRACTURES
⢠Orthopaedic emergency
CLASSIFICATION-
1)GUSTILO AND ANDERSONS
TYPE 1- wound <1 cm
TYPE II- wound 1- 10 cm, soft tissue normal
TYPE III-wound > 10 cm
soft tissue are devitalized and contaminated
42. ⢠TYPE IIIA- with extensive soft tissue injury but with adequate soft
tissue to cover the # bone
⢠TYPE IIIB-extensive soft tissue damage and loss
- bone cannot be covered
⢠TYPE IIIC-with vascular injuries
⢠2)TSCHERNE CLASIIFICATION
⢠3)AO CLASSIFICATION
43. ⢠APPROACH IN OPEN FRACTURES-
⢠General examination-vitals
⢠Examination of other system-
⢠Then examination of open #
44. AIMS OF M/M
⢠To convert the contaminated wound into clean wound and thus help
to convert an open # into a closed one
⢠To establish union in good position
⢠To prevent infection
APPROACH
⢠Stabilise the vital and general condition pt first
⢠Keep the wound covered with proper sterile bandages until the
patient is ready for surgery
⢠Open # are surgical emergency and sx to be done once the pt is fit
45. ⢠DEBRIDEMENT-consists of following steps
⢠Exploration of wound
⢠Excision of all non viable tissue
CIrteria to assess tissue viability
color âpink âpale
consistency-firm-flabby
capacity to bleed-+,-
contractility-+,-
46. ⢠Evacuation-of foreign bodies like dirt,glass,stones,pebbles etc.
⢠Fb are source of infection may invite aforeign body reaction
⢠Hence they hav to be removed by a through irrigation
⢠External fixators are used for fracture fixation after debridement
- help to stabilize # fragments
- allow daily wound inspection and dressings
- permits procedure like ssg for wound covering
- allow soft tissue healing and early mobilisation
48. ⢠ANTIBIOTICS ,ANALGESICS,TETANUS PROPHYLAXIS
⢠External fixation can be used as definitive treatment of fracture,or can
be removed after 2-3 weeks if soft tissue is healed for definitve
procedure like plate ,screw ,interlocking nail etc.
49. APPROACH TO A POLYTRAUMA CASE
Initial evaluation
⢠A-AIRWay
⢠B-breathing
⢠C-circulation
⢠D- disability
⢠E-Exposure
⢠F-fracture examination
⢠G-go back to the beginning for a2ndary survey
⢠H-help