Transcript Extremity trauma

Extremity trauma
General principles
Dr . Almaghrabi Issam
Damascus Hospital
Definition of fracture
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Loss of continuity in the substance of bone
Causes
1.
Causes of trauma
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2.
Car accident
Work accident
Sport accident,…
Mechanism of trauma
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Direct shock
 Serious
 soft tissue lesions
Indirect shock
 Flexion
 Torsion
 compression
General aspects
A.
According to the type of bone:
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Long bones
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Diaphysis
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Epiphysis
* extra-articular
* intra-articular: difficult treatment , ↑↑ complications
Short bones
•
Scaphoid , Calcaneus, Talus,…
Present diagnostic , therapeutic and prognosis problems
Long bones
Diaphysis
•
Epiphysis
extra-articular
intra-articular
Short bones
 soft tissue lesions
According to the age
B.
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Elderly
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Young adult
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Minor trauma
↑↑ morbidity & mortality
e.g. femoral neck fracture
Violent trauma
The risk is local , preserve function
Infant
Minor trauma
Violent trauma
D
Fracture avec décollement
épiphysaire de type 1
G
Fracture en « motte
de beurre » et « bois vert »
Diagnosis of fractures
History
A.
1.
Trauma itself :
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2.
Circumstances of the accident
Mechanism of the injury: direct, indirect
Time of accident
Traumatized patient
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Functional signs : pain, immobility…
Age , past history.
Clinical exam (comparative):
B.
Local examination : signs of the fracture
i.
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Inspection : deformation, edema, hematoma, ecchymosis
Palpation : tenderness, abnormal mobility.
Regional examination
ii.
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Cutaneous : open fractures, contusion….
Vascular: peripheral pulse, color & temperature
Neurological: e.g. humeral fracture (radial n.)
General examination:
iii.
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Clinical: associated lesions
Para clinical : ECG, blood analysis, chest X-ray
X-ray examination:
C.
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Technique:
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The rule of 2:
2 views , 2 joints , 2 limbs , 2 times
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Sometimes a special X-rays, e.g. scaphoid.
Results :
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Site
Type
Displacement : depending on the distal fragment.
Pitfalls
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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 → 5th base metatarsal fracture.
Epilepsy + shoulder pain → think about post. dislocation.
Monteggia – Galeazzi (associated dislocations)
Elderly patient + unable to weight bear
D0
Snuff-box pain + normal X-ray
D 21
Dashboard lesions
Fall from height
Ankle sprain
Epilepsy
Post. dislocation
Galeazzi Fracture
Monteggia Fracture
25
Treatment
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Primary aims :
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Bony union without deformity
Restoration of function
ER treatment :
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Alignment of the fracture
Temporary splintage
Open fractures : sterile bandage , AB , tetanus
Treatment
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Simple fractures:
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±Reduction + casting :
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After care of patient in plaster
swollen fingers – blue – pain → bivalve the cast
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Complex fractures : admission
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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
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external fixation: open fractures
Casting
Ostéosynthèse du tibia par plaque vissée
Infant
Flexible Titanium Nailing of Tibia
Ostéosynthèse du col fémoral
Bi polar
Evolution
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Favorable : consolidation within the expected time .
Complications:
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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
Volkmann
Non union
Malunion
Sudeck atrophy
Records
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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.)
Communications
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Telephoning description
Anatomy
of the fracture :
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Age of patient
Occupation
Type of accident
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The rule of 6 A’s
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(proximal tibia )
Articular
Extra vs Intra
Alignment
A.P. view
Angulation
Lat. view
Apex
Distal fragment
Apposition
75% , 25%
Fracture clinic
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What , When
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3 A’s (assessment , action , advice)
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When , What
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.
3 A’s
Assessment :
Appropriateness (whether this was the best
treatment )
Action :
too tight plaster → split
More senior opinion → ↑↑ Outcome.
Advice :
It is important to Explain to the patient the nature of his injury,
to keep him Informed of his progress
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.
Questions ????