Transcript FRACTURES

FRACTURES
And other Orthopaedic
Disorders
Jill Cavaiuolo
Fracture Definition
• Description: A fracture is a medical
condition in which a bone is cracked or
broken. While many fractures are the
result of high force impact or stress, bone
fracture can also occur as a result of
certain medical conditions that weaken the
bones.
CLASSIFICATION OF #
Open fracture (Also called compound fracture.) - the bone
exits and is visible through the skin, or a deep wound that
exposes the bone through the skin.
Closed fracture (Also called simple fracture.) - the bone is
broken, but the skin is intact.
Complete- the bone is completely broken in two or more
pieces
Incomplete-the bone is not broken all the way through
Direction of Fracture Line
Transverse
Oblique
Spiral
Comminuted
Compression
Categories of Fractures
• In a compound fracture, also called an
open fracture, the bone breaks through
the skin; it may then recede back into the
wound and not be visible through the skin.
Categories of Fractures
•
In a simple fracture, also called a closed
fracture, the bone breaks but there is no
open wound in the skin.
Categories of Fractures
• Complete fractures
refer to the way the
bone breaks: In a
complete fracture, the
bone snaps into two or
more parts..(i.e. #
ulna)
• Incomplete fractures
have a bone that
breaks, but does not
go all the way through.
Fracture Categories
http://www.hughston.com/hha/b_14_2_1a.jpg
Common Fractures
Greenstick - incomplete fracture. The
broken bone is not completely separated.
Common Fractures
• Transverse - the break is in a straight
line across the bone.
Common Fractures
• Spiral - the break spirals around the
bone; common in a twisting injury.
Common Fractures
• Oblique - diagonal break across the
bone.
http://brighamandwomens.staywellsolutionsonline.com
Common Fractures
• Compression - the bone is crushed,
causing the broken bone to be wider or
flatter in appearance
http://brighamandwomens.staywellsolutionsonline.com
Other types of Fractures
• An impacted fracture is one whose ends
are driven into each other. This is
commonly seen in arm fractures in
children and is sometimes known as a
buckle fracture.
• Other types of fractures are pathologic
fracture, caused by a disease that
weakens the bones, and stress fracture, a
hairline crack.
Examples
Xray Example
• This xray indicates a lateral view of an
oblique fracture to the mid humerus.
Closed Oblique Fracture
• This fracture is considered to be mildly
displaced.
Types of Fractures
• Mildly displaced spiral fractures of the
Tibia and Fibula.
Types of Fractures
• Comminuted and mildly displaced
fractures of the distal Tibia and Fibula.
EXAMPLE: A 57 year old 350 lbs. man who puts
significant pressure on his ankle as he walks.
Diagnosis
PILON FRACTURE
This is a comminuted fracture of the
distal tibia due to axial compression
of the ankle joint. It is frequently
associated with a fracture of the
distal shaft of the fibula as well.
WARNING
GRAPHIC TRAUMA
PICTURE
Open Fractures
• A break in the skin and
underlying soft tissue
leading into, or
communicating with
the fracture and its
hematoma
WARNING
THE NEXT TRAUMA
SLIDE IS VERY GRAPHIC
Open Fracture
REVISION
Define Fracture
• Define Open and Closed #
• Define Complete or Incomplete #
• Give examples of classification based on
the direction of # line.
• Define the following types of fractures.
Did you answer that it is a closed comminuted fracture
of the femur?
Transverse complete # of Fibula
Compound(open) # of Tibia and Fibula. The tibial
break looks oblique, and the fibula appears to be
comminuted.
Fractures—Signs and Symptoms
• Some clearly present (compound fracture)
or obvious deformity
• Swelling, tenderness, altered sensation
• Inability to move limb
• Crepitus
– Grating sound heard if ends of bone
fragments move over e/other
• Pain immediately after injury
– Can be delayed if nerve damage in
area
• Diagnostic Tests
– X-rays
Fractures- Complications
• Muscle spasm
– Due to local pain and irritation
– Pulls bone fragments further out of
position
– Causes angulation (deformity) and
rotation of bone which can cause
more soft tissue damage, bleeding,
and inflammation.
• Infections
– Tetanus, osteomyelitis
– In Compound fractures or when
surgery needed precautions taken
(antimicrobials, tetanus booster shot)
# Wrist: Note Swelling in top and bottom picture and
deformity in the compound (open) fracture below.
Complications
• Ischaemia
– Develops in limb following treatment
– Occurs as oedema increases in 1st 48
hrs after trauma and casting.
– Can be due to cast becoming too tight.
• The affected part becomes pale,
pulseless, painful, paralysed, paraesthetic
and 'perishing with cold' ('the 6 Ps').
• Fixed mottling of the skin implies
irreversible changes.
• The limb may be red when dependent,
leading to a misdiagnosis of inflammation,
e.g. gout or cellulitis.
Complications Cont.
Compartment syndrome:
– Develops shortly after fracture when
more extensive inflammation (crush
fractures)
– Increased pressure of fluid w/in fascia
causes severe pain and ischemia or
necrosis of muscle
– Pressure effects can be aggravated by
cast
Compartments of Lower Leg
Compartment Syndrome
Pressure Release
Compartment Syndrome
•
www.residentandstaff.com/issues/articles/2007-03_01.asp
Complications Cont.
• Nerve damage
– w/ severe trauma or tearing of
periosteum
• Failure to heal (nonunion) or healing of
bone w/ deformity (malunion)
– Results if bone is not stabilized with
ends closely approximated and aligned
• Fractures at or near joint may have longterm effects
– Osteoarthritis or stunted growth
Complications Cont.
• Fat emboli
– Risk when fatty marrow escapes from bone
marrow into vein w/in 1st week after injury
– More common in fracture of pelvis or long
bones, especially if not well immobilized after
injury
– Can travel to lungs and cause obstruction,
extensive inflammation, and respiratory
distress
Fat Embolism
• Fat Embolism Syndrome
– Globules of fat, released from fractured
bone
– Fat mixes with platelets
• Emboli travel to lungs, brain, or other
areas.
– Clotting cascade activated = petechiae
Fat Embolism Syndrome
• Signs and Symptoms
– Dyspnoea
– Confusion
– Pulmonary complications
– Pulmonary Oedema
– ARDS(Acute Respiratory distress
syndrome)
– Petechiae-small spots on the skin
Complications-DVT
Closed Fracture Considerations
• The energy of the
injury
• Degree of
contamination
• Patient factors
• Additional injuries
Fractures—Treatment
• Management of Pain,nausea etc.
• Cleaning the wound if open-may be
done in theatre
• Immediate splinting and
immobilization
• Reduction of bones to restore normal
position
Closed reduction: exerting pressure and traction
Open reduction: requires surgery
• Pins, rods, plates, screws
Splinting and Immobilization
– Casting with plaster or fiberglass, and
splints .
Closed Reduction
Traction
Application of force or weight
pulling on limb that is opposed
by body weight
Force maintains alignment of
bones, prevents muscle
spasms, and immobilizes the
limb
Open Reduction
• Internal fixation of Radius
External Fixation
•
This is a patient treated with an external
fixator, which is used to treat fractures that
are too unstable for a cast. You can
shower and use your hand gently with the
external fixator in place.
Internal Fixation
Fractured Pelvis
Internal Fixation
Trans articular pin fixation
Fractures—Pathophysiology:
Factors Affecting Healing Process
• Amount of local damage to bone and soft
tissue
– Major determining factor
– Prolonged inflammation or extensive
damage to bv or periosteum impairs
healing
• Amount of realignment and approximation
– Closer the ends of the bones are, the
smaller the gap to fill, the faster the
healing process
• Secondary problem
– Foreign material or infection delays
healing
Factors Affecting the Healing
Process
• Numerous systemic factors
– Delayed healing in elderly pts w/
circulatory problems, diabetes
mellitus, anaemia, nutritional
deficits, steroid therapy.
Bone Healing
• As soon as a fracture occurs, the body
acts to protect the injured area, forming a
protective blood clot and callus or fibrous
tissue.
• New "threads" of bone cells start to grow
on both sides of the fracture line. These
threads grow toward each other.
• The fracture closes and the callus is
absorbed.
Fractures—Pathophysiology of Bone
Repair
Nursing Management
General Observations for pins, traction
and casts include:
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•
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Skin inspection hourly
Neurovascular observations ½ -1 hourly
Limb alignment
Limb exercises
Signs of infection –warmth, swelling, pain,
odour, discharge
Nursing Management
• Elevation
• Monitor Pt. pain and comfort
• Remind Pt. of injured limb and positioning
etc.
• Check bed positioning of Pt to ensure
traction is functioning.
• Check equipment i.e. pulleys, pins etc.
• Pts. with traction must never have weight
bags lifted randomly.
Plaster Management
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Maintain cast integrity
Turn Pt. 1-2 hrly
Use palms when handling wet plaster
Do not cover wet cast-allow to dry
Check cast ooze and outline
Educate Pt. to not shove anything inside of
cast e.g. knitting needles
Plaster Management
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•
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Do not use blow dryer to dry cast
Cast will heat when drying
Cast is heavy
Observe skin around cast edge, skin
breaks can lead to infection
A Case History
A 24 year old right hand dominant man
sustained a compound fracture of his right
forearm as a teenager. He had a deep
infection that required part of the bone to be
removed. His right wrist was severely
deformed and x rays showed bone loss and a
non-union of the fracture.He had surgery that
reconstructed his bone, rehab. and he
returned to work as a full time construction
worker.
http://www.theuniversityhospital.com/limblength/tech.htm
A Case History
Other Disorders
Sprains and Strains
Sprain. A sprain is a stretching or
tearing of ligaments. Ligaments are
tough bands of fibrous tissue that
connect one bone to another.
Common locations for sprains are
your ankles and knees.
Strain. A strain is a stretching or
tearing of muscle or tendon. People
commonly call strains "pulled"
muscles. Hamstring and back
injuries are among the most
common strains
www.mayoclinic.com
Sprains and Strains
• Both easily torn when excessive force exerted
on a joint
• Avulsion
– Ligaments or tendons completely separated
• Painful, tenderness, discoloration (due to
haematoma formation)
• Strength and range of movement of the joint are
limited
• Diagnosis: X-ray,scans etc. to rule out fracture
and to note extent of damage
Sprains and Strains Healing
• Tear, then inflammation, then granulation
tissue
• Collage fibers form to create links w/
existing tissue
• Eventually healing mass bound together
w/ fibrous tissue
• Healing 6 weeks
• Severe damage requires surgery
Dislocation
• Separation of 2 bones at a joint
– Loss of contact between articulating bone
surfaces
– Usually one bone out of position, other normal
– Eg. humerus displaced from scapula
• Subluxation
– Bone only partially displaced w/ partial loss of
contact between surfaces
• Causes considerable soft tissue damage
– Also damage to ligaments, nerves, bv as bone
pulled away from joint
– Inflammation and bleeding
– Severe pain, swelling, tenderness
Dislocation
• Diagnosis confirmed by X-ray
• Treatment
– Reduction to dislocated bone,
immobilization, therapy to
maintain joint mobility
– Healing is slow if ligaments and
soft tissue extensively damaged
History
After breaking a hip, a 70 year old
woman undergoes hip replacement
surgery. After 5 days she comes back
with severe hip pain.
Diagnosis
TOTAL HIP PROSTHESIS SUPERIOR
DISLOCATION
References
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Fracture classification/sprains and strains
www.mayoclinic.com
Radiology Web Site - McGill University
http://sprojects.mmi.mcgill.ca/icmcradiology/index.aspx
Brigham and Women’s Hospital Types of Fractures
http://brighamandwomens.staywellsolutions online.com