Extremity trauma General principles Dr. Almaghrabi Issam Damascus Hospital

Definition of fracture Loss of continuity in the substance of bone

Causes 1. Causes of trauma Car accident Work accident Sport accident,… 2. Mechanism of trauma Direct shock  Serious  soft tissue lesions Indirect shock  Flexion  Torsion  compression

General aspects A. According to the type of bone: Long bones Diaphysis Epiphysis * extra-articular * intra-articular: difficult treatment, ↑↑ complications Short bones Scaphoid, Calcaneus, Talus,… Present diagnostic, therapeutic and prognosis problems

Long bones Diaphysis Epiphysis extra-articularintra-articular

Short bones  soft tissue lesions

B. According to the age Elderly Minor trauma ↑↑ morbidity & mortality e.g. femoral neck fracture Young adult Violent trauma The risk is local, preserve function Infant

Violent traumaMinor trauma

Fracture avec décollement épiphysaire de type 1 G D

Fracture en « motte de beurre » et « bois vert »

Diagnosis of fractures A. History 1. Trauma itself : Circumstances of the accident Mechanism of the injury: direct, indirect Time of accident 2. Traumatized patient Functional signs : pain, immobility… Age, past history.

B. Clinical exam (comparative): i. Local examination : signs of the fracture Inspection : deformation, edema, hematoma, ecchymosis Palpation : tenderness, abnormal mobility. ii. Regional examination Cutaneous : open fractures, contusion…. Vascular: peripheral pulse, color & temperature Neurological: e.g. humeral fracture (radial n.) iii. General examination: Clinical: associated lesions Para clinical : ECG, blood analysis, chest X-ray

C. X-ray examination: Technique: The rule of 2 : 2 views, 2 joints, 2 limbs, 2 times Sometimes a special X-rays, e.g. scaphoid. Results : Site Type Displacement : depending on the distal fragment.

Pitfalls Elderly patient + unable to weight bear → femoral neck fracture Snuff-box pain + normal X-ray → suspected scaphoid fracture Dashboard lesions → 2 patellae, femoral shaft, silent hip dislocation Calcaneus fracture → the other calcaneus + vertebral column. Ankle sprain → 5 th base metatarsal fracture. Epilepsy + shoulder pain → think about post. dislocation. Monteggia – Galeazzi (associated dislocations)

Elderly patient + unable to weight bear

D 21 D 0 Snuff-box pain + normal X-ray

Dashboard lesions

Fall from height

Ankle sprain

Epilepsy Post. dislocation

Galeazzi Fracture

Monteggia Fracture

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Treatment Primary aims : Bony union without deformity Restoration of function ER treatment : Alignment of the fracture Temporary splintage Open fractures : sterile bandage, AB, tetanus

Treatment Simple fractures : ±Reduction + casting : After care of patient in plaster swollen fingers – blue – pain → bivalve the cast Complex fractures : admission Traction : skin – skeletal Open reduction & internal fixation Indications Failed closed reduction Fractures cannot be held by closed methods (femoral neck) Intra-articular fractures Multiple injuries Techniques Plates, screws, K-wires, nails Interlocking nail, elastic flexible nails external fixation: open fractures

Casting

Ostéosynthèse du tibia par plaque vissée

Infant Flexible Titanium Nailing of Tibia

Ostéosynthèse du col fémoral

Bi polar

Evolution Favorable : consolidation within the expected time. Complications: Immediate : General : choc Loco-regional : skin, vascular, nerves Secondary : General : DVT, bed sores, infections, fat embolism Loco-regional : secondary displacement, opening, necrosis, Volkmann. Late : Delayed union, nonunion, malunion, arthritis, AVN Functional : pain, stiffness, Sudeck. infection

Volkmann

Non union

Malunion

Sudeck atrophy

Records Date & time, legible hand writing, employ only common use contractions. Full record on the day of the admission Write results of X-rays (neg., pos.)

Communications Telephoning description of the fracture : Age of patient Occupation Type of accident The rule of 6 A’s Articular Extra vs Intra Anatomy (proximal tibia ) Angulation Lat. view Alignment A.P. view Apposition 75%, 25% Apex Distal fragment

Fracture clinic What, When 3 A’s (assessment, action, advice) When, What

What, When What : What we are dealing with (diagnosis) Recording ↓↓ duplication. When : Establish the time that has passed since the patient’s injury Initial Medical record and X-rays are available.

3 A’s A ssessment : Appropriateness (whether this was the best treatment ) A ction : too tight plaster → split More senior opinion → ↑↑ Outcome. A dvice : It is important to Explain to the patient the nature of his injury, to keep him Informed of his progress

When, What When: the date & time of the next appointment. e.g. ↨ of stitches, ↨ of plaster What : The purpose of the patients next visit Save valuable time by avoiding the patient having to wait and seen twice.

Questions ????