2. Extremity trauma General principles Dr. Almaghrabi Issam Damascus Hospital

3. Definition of fracture Loss of continuity in the substance of bone

4. 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

5. 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

6. Long bones Diaphysis Epiphysis extra-articularintra-articular

7. Short bones  soft tissue lesions

8. 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

9. Violent traumaMinor trauma

10. Fracture avec décollement épiphysaire de type 1 G D

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

12. 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.

13. 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

14. 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.

15. 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)

16. Elderly patient + unable to weight bear

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

18. Dashboard lesions

19. Fall from height

20. Ankle sprain

22. Epilepsy Post. dislocation

23. Galeazzi Fracture

24. Monteggia Fracture

25. 25

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

27. 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

28. Casting

32. Ostéosynthèse du tibia par plaque vissée

33. Infant Flexible Titanium Nailing of Tibia

35. Ostéosynthèse du col fémoral

36. Bi polar

39. 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

40. Volkmann

41. Non union

42. Malunion

43. Sudeck atrophy

44. 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.)

45. 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

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

47. 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.

48. 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

49. 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.

50. Questions ????