2. Second Lecture Skeletal trauma (Axial and peripheral (Upper and Lower extremities)

3. Definitons 1.Fracture: complete disruption in the continuity of bone 2.Dislocation: complete disruption of a joint, articular surfaces are no longer in contact 3.Subluxation: minor disruption of a joint where some articular content remains Description of fractures 1. Bone involved 2. Size and extent 3. Type 4. Direction of fracture line 5. Alignment of fragments 6. Any impression, depression or compression

4. General principles of trauma evaluation by plain x-rays Principle of “twos” ( 2 views, 2 joints 2 times ) Anteroposterior view and lateral view

5. Principle of “twos” Each view including 2 adjacent joints

6. Description of fractures Bone(s) involved Size and extent

7. Description of fractures Type of fracture complete / incomplete Complete 1.simple 2.comminuted

8. Description of fractures incomplete 1.bowing 2.torus 3.greenstick

9. Description of fractures Alignment Displacement Medial lateral

10. Description of fractures Alignment Angulations Medial lateral

11. Description of fractures Alignment Rotation internal rotation external rotation

12. Description of fractures Alignment shortening lengthening -shortening lengthening

13. Description of fractures Direction of fracture line oblique transverse

14. Description of fractures Direction cont’d spiral longitudinal

15. Fracture: A Fracture is a structural break in the normal continuity of bone. 1-Fracture types: A - Simple and Compound fractures: 1} Simple Fracture: The Skin remains intact 2) Compound Fracture: Fracture is communicating with the exterior through a laceration in the skin or mucous membrane.Laceration may be caused by fracture fragments or by the object causing the fracture.

16. 2- Fracture lines 1)Green stick: Incomplete fracture which occurs in children. It is the simplest type of fractures which heals rapidly with potentially complete reconstruction of the preexisting architecture“ 2)2) Transverse or linear fracture * Complete fracture of the bone Heals with adequate fixation of the bone 3) Spiral fracture A more severe type of fractures may need internal fixation 4) Comminuted fracture: Multiple bone fragments are present at the fracture site

17. Complications of fractures І- Union problems A - Mal-union and cross union B -Delayed union C- Non union ІІ - Sudeck's atrophy ІІІ - subperiosteal hematomas І V- A vascular necrosis

18. І- Union problems Improper union, the description of the fracture refers to the position of the distal fragment relevant to the proximal fragment, Possible types includes; 1-Angulation (anterior, posterior, medial and lateral) 2- Shortening (over lap.overriding) A-Mal union

19. 3-Cross-union It occurs when 2 adjacent bones are fractured e.g. tibia, fibula or ulna and radius when healing occurs, the proximal end of one bone heals with distal end of the other bone This may cause severe problems interfering with the function e.g. when cross union occurs between the tibia and fibula (fibula is a weak bone that can't maintain the body weight) Investigations X.ray should be performed in 2 views, antroposterior and lateral

20. Management (ttt) In case of mal-union-the bone may need to be re-fractured then accurate reduction is applied to restore the normal anatomy to be followed by stabilization and immobilization.

21. Causes of union problems 1-lnadequate fixation e-g cast was not tight enough 2- Interposition of soft tissue A muscular tendon is interposed between the fracture edges preventing healing 3- Infection *The liability for infection increases In compound fractures more than in simple fractures * The presence of bacteria and pus delay the union process * In compound fractures, Tetanus toxoid and broad spectrum antibiotics should be given 4- Bad general condition of the patient Old patients or patients with systemic diseases e.g diabetes usually show delayed union or even non union

22. B - Delayed union Normally healing occur within 6-8 weeks in adults. Visualization of fracture line in the follow up x rays long time after the expected lime of healing with poor callus formation=delayed union Treatment The Cause of delayed union is treated if possible (nutrition, antibiotics and re fixation if needed)

23. C) Non-union The reaction of healing comes to an end without union of the fracture The fracture lines are seen with poor callus formation and sclerosis of the fracture edges Treatment Exposure and excision of sclerosed edges & coaptation of the raw edges by Internal fixation e.g. intramedulllary nail and Bone grafting if needed

24. ІІ- Sudeck's Atrophy: Etiology: Bone dystrophy due to unknown cause but thought to be due to 1-Reflex vascular stenosis 2-Disuse atrophy after removal of splints Pathology: Marked osteoporosis distal to the fracture site, most commonly in the hand following fracture of radius

25. Radiological diagnosis of spine fracture l-Plain X ray Antero posterior, lateral views (most important). 1) Vertebral fracture a)Burst/comminuted: The vertebra shows decrease height and fragmented body b)A NTERIOR wedging: Anterior aspect of vertebral body is shorter than posterior border C) Tear drop: common in cervical region

26. 2- Ligamentous iniury leads to Subluxation and Dislocation movement of vertebral body at the fracture level usually indicate ligamentous injury. the lower vertebra moves either posteriorly (posterior subluxation) or anteriorly(anterior subluxation)

27. N.B Fractures Of Neural Elements: This may occur with fracture of vertebral body at the level of injury or above as well as below the level Ligaments: Ligamentous injury usually leads to Unstable fracture which leads to Subluxation or dislocations of vertebral body

28. Complications of spinal trauma:  Spinal cord lesions (edema, contusion, hemorrhage, laceration and transaction). Cord atrophy & syrinx later on.  Intraspinal and paravertebral hematomas  Disc bulge and herniation.

29. Skeletal Trauma Spinal Trauma Trauma of the spine affects one or more of the following: { 1} Bones (vertebrae-neural elements.) {2} Spinal cord {3} Ligament {4} paravertebral soft tissue (muscles)

30. Bones: Fracture of vertebral body or neural elements (laminae, pedicles, spinous process) Fractures of vertebral bodies A) Burst Fracture It occurs with axial trauma e.g. falling from a height. The most common level is D12-L1 vertebrae B ) Anterior Wedging: it is the most common type spinal fractures, very common in lumbar vertebrae. The vertebra collapse anteriorly and is usually subluxated posteriorly C) Tear-drop fracture: Common in cervical region

31. 3)subperiosteal hematoma Collection of blood under the periostium is normally, small hematoma is formed in the soft tissues around the fracture site. Then invaded by granulation tissue. This process stimulates healing of the fracture. If the nutrient artery of the bone becomes injured due to fracture, large hematoma may be formed This large hematomas heal by calcification, a condition which causes disfigurement especially in apparent areas e.g. clavicle or hand Treatment Surgical excision of the calcified hematoma

32. 4- Avascular necrosis It occurs when the nutrient arteries of the bone become injured, so that, the part of the bone which is supplied by the artery becomes deprived from its blood supply leading to its death Example: The most common example is avascular necrosis of the head of femur following fracture of the neck of femur It occurs in about 15-35% of cases It appears in X ray as increase in bone density of the femoral head with loss of volume and irregular contour

33. Some other local complication of fracture:  Skin injury, necrosis & gangrene  Vascular injury (arteries or veins)  Neurological injuries (peripheral nerves)  Muscular and tendon injury  Joint complications: Stiffness, Secondary osteo- arthritis, infection General complication of fractures: 1- hemorrhage and stroke 2- Crush syndrome 3- Pulmonary embolism 4- fat embolism 5- Tetanus 6- Complications of prolonged recumbancy e.g. bed soars...

34. Imaging Technology 1.X-RAYS: These show (1) disc narrowing, (2) bone spurs (osteophytes), and (3) vertebrae slipping off another (spondylo-listhesis) 2.CAT SCAN: This is a computerized X ray that shows how much the diameter of the canal is reduced and how far out the discs are. 3.M.R.I. (Magnetic Resonance Imaging): It produces picture like the CAT scan but they are generated using a magnetic field (instead of radiation) – not needed if the CAT scan shows the problems. 34

40. Fracture lateral malleolus Oblique fracture

41. Burst # of C7 C2 C7

42. Burst # of the spine

43. MRI

44. Burst # of the spine CT & Plain

45. Burst # of the spine

46. Burst # of the spine CT

47. CT & Plain x ray of burst fx

48. A vascular necrosis

51. DDX for both hips

52. A vascular necrosis Head of the femur

53. Comminuted Fractures

54. Fracture lower end of humerus plain X- Ray lateral view

55. Comminuted Fractures

61. Tear drop # of the spine

62. Dislocation

66. C2-C3 Fracture/Dislocation

67. C6-C7 Vertebral Dislocation

68. Dislocation

69. Dislocation & fx Dislocation

70. Elbow dislocation

71. Subluxation

72. Atlanto axial subluxation

73. Internal fixation of upper tibia

75. Simple #

76. Comminuted fx

77. Simple fx

79. Transverse #

84. Wedge fractures

87. Anterior wedge fracture