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Displacement. Described as: Distal in relation to proximal Un-displaced Shift Sideways Shortening Distraction Angulation In all planes Rotation. Fracture Diagnosis. Clinical features Imaging: Radiology (x-Ray). Clinical Features. History of Trauma Symptoms and signs: Pain Swelling - PowerPoint PPT Presentation
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Displacement
Described as: Distal in relation to proximal
Un-displaced
ShiftSidewaysShorteningDistraction
Angulation In all planes
Rotation
Fracture Diagnosis
Clinical features
Imaging: Radiology (x-Ray)
Clinical Features
History of Trauma
Symptoms and signs:1. Pain
2. Swelling
3. Deformity
4. Bony tenderness
5. Abnormal movement
6. Crepitus
7. Loss of function
Approach - history
Details of injuryMechanism, force, bleeding, consciousness, …
Details of factureDeformity, pain, loss of function, ..
Other medical problems
Anti-tetanus status if open injuries
Careful:Fractures are not always at the site of impactSome fractures do not need severe force
Approach – clinical exam
General medical conditionshould be evaluated to exclude
shockbrain injuryother problems
Vital signsshould be observed and followed up
Approach – clinical exam
Look:Adequate exposureGeneral on patientLocal:
Swelling, deformity, bruises, color, …Special attention is to be paid to wounds
Approach – clinical exam
Feel:Tenderness, distal pulses, temperature and crepitus
on movementSensory and motor deficitsPulse distal to injuryCompartment syndrome
Move:With care
make sure not to cause more pain or injuryCrepitus & abnormal movement indicates a fractureJoints distal to the affected area
Approach – clinical exam
Examination of the visceraLiver and spleen in rib fracturesUrinary bladder and urethra in pelvic fracturesNeurological examination in head and spinal injury
Investigations - Imaging
X-rays:Low of 2s
Two views: AP and LateralTwo joints: Above and BelowTwo sides: Right and LeftTwo occasionsTwo Doctors !
Special views:Obliques, Tunnel view, skyline, functional flexion /
extensionArthrography:
Shows intra-articular structuresFunctional in hip
Imaging
Plain x-ray: (law of twos)Two views:AP and Lateral
Apley’s System of Orthopedics & Fractures
AP
AP
Lat
Lat
Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint below
Apley’s System of Orthopedics & Fractures
Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison
more in children to
compare epiphysis
Apley’s System of Orthopedics & Fractures
Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison
more in children to
compare epiphysisTwo occasions
e.g. stress fracturese.g. scaphoid fracture
Apley’s System of Orthopedics & Fractures
Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison
more in children to
compare epiphysisTwo occasions
e.g. stress fracturese.g. scaphoid fracture
Two injuriese.g. patellar fracture and hip injurye.g. calcaneal fractures & spine injuries
www.jumpintheair.com
Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison
more in children to
compare epiphysisTwo occasions
e.g. stress fracturese.g. scaphoid fracture
Two injuriese.g. calcaneal fractures & spine injuries
.....and two Doctors!
www.123rf.com/
Imaging
Plain x-ray: (law of twos)
Special views:Calcaneal viewShoulder dislocation: axial viewScaphoid viewsAcetabular fractures: 45o tilt views
http://osuemed.wordpress.com/
Imaging
CT Scan:In complex and ntra-articular fracturesIn spineIn pelvic and acetabular fracturesIn calcaneal fractures
www.learningradiology.com
Imaging
MRIShow associated injuries in spinal fracturesAssociated soft tissue injuries – e.g. kneeHidden fractures:
Subtrochanteric (ST) disruptionStress (fatigue) fracturesScaphoid fracture
Suspected avascular
necrosis
www.highperformancesports.blogspot.comwww.bjj.boneandjoint.org.uk
Fracture healing
A broken bone heels because …..it is broken !
Alan Apley
Natural bone healing
Movement at the fracture site initiates a healing process—callus formation
Vascular and cellular response leads to tissue differentiation and mineralization resulting in restoration of mechanical integrity
Natural bone healing
http://classes.midlandstech.edu/
Cascade of tissue differentiation
Following a Fracture:
1. Hematoma
2. Granulation tissue
3. Connective tissue
4. Fibrocartilage
5. Mineral deposition
6. Bone
Fracture healing1. Inflammation
Hematoma Mesenchymal cells
2. Soft callus Granualation tissue
3. Hard callus Intramembranous bone
formation Enchondral ossification
4. Remodeling bony bridging
Cellular and Vascular Reaction
cells haematoma granulation tissue
Tissue Differentiation
connective tissue
granulation tissue
Giemsa
Tissue Differentiation Cascade
Cartilage formation
BoneMineral deposition
Masson-Goldner
Healing time & strength
Process Timing Strength
Hematoma 2 hrs 1%
Inflammation 2 days 5%
Soft callus 2 weeks 25%
Hard callus 2 months 74%
Re-modelling 2 years 100%
Fracture Healing
Conditions necessary for bone healing:Good blood supplyControlled motionNo infection
Fracture Healing
Unfavorable factorsImpairment of blood supplyInfectionExcessive movementPresence of tumorInterposition of soft tissueAny form of Nicotine (smoking)Bad nutrition
Average healing time
Children: Upper limb: 3-4 weeksLower limb: 2X upper limb (6-8 weeks)
Adults:Upper limb: 2X children (6-8 weeks)Lower limb: 2X upper limb (12-16 weeks)
Fracture Treatment
Aim of fracture treatmentaid healing,in normal position,avoiding complications
Fracture treatment
Treat the patient, not only the fracture
Reduce the fracture
Immobilize the fracturePrevents displacementAlleviates painPromotes soft tissue healing
Mobilize the patient
Avoid complications