Introduction

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* References

Outline of orthopedics.Mercers’ orthopaedic surgery.Apley's system of orthopedics & fractures.

* Fracture definition

It is a break in the structural continuity of bone .It may be no more than a crack, a crumbling or splintering of the cortex ;more often the break is complete &the bone fragment are displaced.


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* How fracture happen?

1.from single traumatic incident. 2.repetitive stress (fatigue). 3.abnormal weakening of the bone, (pathological fracture).


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* In cancellous bone trauma produce comminuted crush fracture. Around joint pulling ligament and tendon produce avulsion fracture.


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* How fracture are displaced

Either by force of the injury. Gravity. Partly by pull of the muscle attached to them.

* How fracture heal

Tissue destruction and haematoma formation. Inflammation and cellular proliferation occurs within 8 hours. clotted haematoma is slowely absorbed and fine capillaries grow into the area then (granulation tissues).


* Callus formation is driven by inductive proteins. Consolidation (woven bone is transformed into lamellar bone) takes several months. Remodelling occurred over a period of months or even years.

* Perkins’ time table

* upper limb . Spiral fracture 3 weeks united * 2 consolidation. Lower limb * 2. Transverse fracture * 2 again.

* In children the time shorter, in elderly longer

* OR THERE MUST BE CLINICAL AND RADIOLOGICAL evidence of consolidation before full stress is permitted without splintage

* CLINICAL FEATURES

History. General sign. Local signs. X-ray. Special imaging.

* history

There must be usually a history of injury ,followed by inability to use the injured limb.BE WARE ……The fracture is not always at the site of the injury,a blow to the knee may fracture the patella ,femoral condyle ,even the acetabulum.

* Pain are common symptom. bruising ,swelling Deformity. Numbness,loss of movement , History of previous injury. General medical history.

* General signs

A broken bone part of a patient so look for .Hemorrhage.Associated damage to brain,spinal cord ,viscera.Predisposing cause (pagets’ disease).

* Local signs

Look : swelling, brushing, deformity, state of the skin.


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* Feel

Tenderness, distal pulse, and sensation

* Move

Crepitus and abnormal movement, movement of the joint distal to the injury

* Roles of X-RAY to be followed

2 Views
2 Joints
2 Limbs
2 Injuries
2 Occasions
A p & Lateral
Forearm& leg
In Children
Fracture calcaneum
Frcature scaphoid



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* Special imaging

1.TOMOGRAPHY: In spine or tibia condyle injure.

* 2.CT,M.R.I.: In spine fracture which threatened the cord.

* RADIO- ISOTOP scanning: In stress fracture or undisplaced fracture.


* Secondary injuries
Fracture spine cord injure.

Fracture pelvis abdominal viscera injuries (intestine, diaphragm). .


* Fracture ribs lung ,heart .Fracture and dislocation around pectoral girdle: brachial plexuses& vessels.

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* Treatment of closed fracture

General treatment
Treatment of fracture

* General treatmentat the accident site

Air way . Protection cervical spine. Breathing. Bleeding stoppage . by direct pressure or by tourniquets. (time) (Circulation) Fluid replacement

* Examination .Analgesia.Splintage to reduce pain, blood loss …….Transport .by proper stretcher.

* In the hospital

Rapid survey. Constant re-evaluation. Definitive care.


* treatment of fracture
REDUCE
HOLD
PHYSIOTHERAPY

* Reduction

Conservative (closed). Operative (open).

* Manipulation (reduction)

A: closed reduction: Under /anesthesia, with assistant. Used in children fracture, Minimally displaced fracture. Fracture not unstable after reduction.


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* Reduction

B:Open reduction. If failure close. Articular joint involvement. Two bone fracture.

* HoldI. Continuous traction

* 1.Traction by the gravity.

For upper limb injure.

* 2.Skin traction

Not more (4-5KG) e.g. fracture in children.


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* 3.Skeletal traction:

By stein Mann pin or Denham pin. >5KG.


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* 4.Fixed traction
In Thomas splint.

* 5.Balanced traction

Over pulleys.

* 6.Combined traction.

* COMPLICATIONSof skin and skeletal
1.may constrict circulation (gallows traction). 2. Nerve injuries (peroneal). 3.compartment syndrome.


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* II-cast splintage

Plaster of paris(pop)


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* Complications

1.fracture disease: stiffness, atrophy, osteoporosis, edema. 2.tight cast. 3.pressure sores. 4.Skin laceration

* III-Functional bracing

Is one way of preventing joint stiffness while still permitting fracture splintage and loading. E.g.(fracture femur ,fracture tibia).


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* IV-internal fixation
Screw. Plate . Wire. L-plate. Compression screw. K-nail.

* Indications

Failure conservative. Fracture two bones. Intra articular fracture. Pathological fracture. In difficulty nursing patient.

* Complications

Infection. Non union. Implant failure. Re fracture.


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* BE WHERE (fixation removal before one year at minimum and 18-24 months safer.)

* V.External fixation(indications)
Fracture with severe soft tissue injuries. Complicated fracture. Infected non union. Fracture pelvis. Multiple injuries. Bone lengthening. Plastic surgery (flap). Fracture neck femur.


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* Over distraction Reduce load transmission (so dynamization after 6-8 weeks or remove). Pin tract infection.
Complications.



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* Prevention edema: by elevation. Active exercise: So to pump edema fluid and stimulate circulation ,prevent soft tissue adhesion &promotes fracture healing.


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* Assisted movement: By gentle movement only. Functional activity: By improving patient mobility.