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Fifth stage
Surgery-Ortho
Lec-1
د. يقضان
29/11/2015
Introduction to fractures and trauma – 1
Principles of fractures:
Fracture : it is break in the structural continuity of the bone .
It is of two main types :
1- simple fracture ( closed ) .
2- compound fracture (open ) .i.e. associated with wound connecting it to the external
environment .
How fracture happen :
1- single traumatic incident .
2- repetitive stress .
3- abnormal weakening of the bone ( pathological fracture ) .
In single traumatic incident the bone sustained sudden and excessive force which may be
direct or indirect :
In direct force the bone break at the point of impact ; while in indirect force the bone is
break at distant from the site of force where it applied .
The force which break the bone is of different types :
A- twisting force . B- bending force .
C-compression force . D- tension force .
Each of them influence the shape of the fracture which is either spiral ,oblique , transverse ,
or fracture with butter – fly segment .
all this is applied to the long bones .
So the fractures either complete or incomplete :
.
comminuted
, or
oblique , spiral
,
ransverse
t
te could be
Comple
fracture .
compression
or
green stick
And incomplete could be
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Types of fracture displacement
Fracture healing : immobilization of the fracture is not mandatory for fracture healing ; the
splinting of the fracture to ensure :
1- pain relief . 2- union take place in good position .
3- early movement and return to function .
Steps of fracture healing :
1- tissue destruction and haematoma formation .
2- acute inflammatory reaction and cellular proliferation .
3- callus formation (step of union) .
4- consolidation .
5- remodeling .
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Time table :
For fracture healing the time change according to age , blood supply , type of the fracture
……etc.
Perkin`s time table is very simple table to asses that time :
Spiral or oblique fracture in the upper limb unite in 3 weeks .
Transverse fracture in the upper limbs unite in 6 weeks .
For consolidation multiply by 2 .
In the lower limbs :
Oblique or spiral fracture need 6 weeks for union .
Transverse fracture need 12 weeks .
For consolidation multiply by 2 .
Clinical features of the fracture :
A – symptoms :
1- history of trauma followed by inability to use the injured limb ; if the trauma is simple
and weak force we suspect pathological fracture .
2- pain . 3- brusing . 4- swelling . 5- deformity .
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B – signs :
1- swelling . 2- Bruising . 3- deformity . 4- tenderness .
5- crepitus . 6- loss of function .
X – ray : it is mandatory for diagnosis of fractures .
Role of twos :
1- two views .
2- two joints .
3- two limbs .
4- two injuries . e. g. fracture calcaneum .
5- two occasions e.g. fracture scaphoid
6- two tissue .
Special imaging: 1- tomography . 2- C.T. 3- MRI . 4- bone scan .
Treatment of closed fracture :
A – the general treatment is the first consideration i. e. the air way patency , breathing and
circulation .
B – treatment of the fracture itself : this include :
1- reduction .
2- holding .
3- physiotherapy and rehabilitation .
1- reduction of the fracture :
It should be taken in the first 12 hours from the trauma , because the oedema and swelling
make the reduction difficult after that time .
Two types of reduction :
1- closed reduction ( by manipulation ) .
2-open reduction ( by surgical approach ) .
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Open reduction is indicated in :
1- when close reduction fail .
2- when there is large articular fragment need accurate reduction .
3- for traction fractures in which the fragments are held apart .
Holding of the fractures : by :
1- continuous traction .
2- cast splintage ( plster of paris P.O.P) .
3- functional bracing .
4- internal fixation .
5- external fixation .
Traction : types of traction :
1- traction by gravity : this is used only in upper limb .e.g hanging cast .
2- skin traction : it is available in special kit , it is used mainly in the lower limb .
3- skeletal traction .
Skin traction
Principle of it's use :
1- applied distal to the fracture site .
2- weight used is 10% of the body wt. and not more than 5 kg , if we need more than 5 kg
then we use skeletal traction .
3- removal of the hair before application .
Indication of skin traction :
1- used in fractures of the lower limbs vertebras and pelvis .
2- in dislocations of the lower limbs .
3- for resting of the limb e.g. in arthritis , osteomyelitis , septic arthritis , irritable hip etc…
4- in treatment of back ache .
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Complication of skin traction :
1- allergy to the adhesive material of the plaster lead to ulceration of the skin .
2- compression of the vessels lead to compartment syndrome .
3- compression of the nerves lead to neuropraxia .
4- excessive traction (when use over wt.) lead to non union
5- failure of the kit .
3- skeletal traction :
Pin is inserted distal to the fracture site usually behind the tibial tuberosity or lower femoral
condyles , the wt. used is one six (1/6) of the body wt. .
Complication : 1- broken of the pin 2- pin tract infection 3- over (excessive ) traction .
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Methods of traction :
A- fixed traction e.g. Thomas splint .
B- balanced traction ( over pulleys ) .
C- combined traction .
D- counter traction .
Cast splintage (p.o.p) :
Plaster of Paris is calcium sulphate hemihydrates , it is very safe and easily used in holding
of the fractures .
Principles of using p.o.p :
1- in acute fractures , use the p.o.p in form of slabs to avoid compartments syndrome .
2- it should involve the joint below and the joint above of the fracture .
3- never applied directly on the skin (use cotton or any other material) .
4- it should never be done too tight or too loose , too heavy or too light .
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