Fractures

Describing An X-Ray

Site: where on bone; involvement of articular surfaces (describe % of articular surface involved); involvement of epiphysisType: buckle, transverse (<30° angle), oblique (>30° angle), longitudinal, spiral, comminuted (describe number of pieces, displacement of fragments); segmental; butterfly (complex if segment if in >1 piece); torus; greenstick; impacted; depressed; compression; avulsion Oblique and spiral are at risk of displacement and shortening; butterfly is unstable, with delayed union and stiffness commonDisplacement: is less significant than angulation; describe in cm or in relation to width of boneAngulation: in degreesShortening: in cm or Separation: in cmRotation: internal or externalOthers: presence of FB / gas / ST swelling / presence of dislocation

Haemorrhage control: 1.2-1.5L in femur; 0.5-1L in tibia; 500ml in humerusDecontamination ASAP: if open; irrigation (povidine / iodine delays wound healing; antiseptic soaked gauze packs to wound good) early surgical debridement within 6hrsAnalgesia: start with IV opioids; ADT if openAntibiotics: if open; infection with NNT 13; flucloxacillin 2g QID (or cephalothin/cefazolin if allergy); if significant wound soiling / >10cm wound / loss of bone coverage: gentamicin + benzylpenicillin / augmentin; if concern Re: faecal/clostridial infection – high dose penicillin.ADTElevationReduction: immediate reduction of exposed bone or tension on wound edges / displaced # with vascular compromiseImmobilisation: immobilise joints above and below Pros: pain / haemorrhage, protects from further accidental injury, helps transport Cons: no splint on skin for >8hrs without review of NV status; distraction from other injury; local skin pressure and necrosis; compartment syndrome; distal hypoperfusion; more difficult assessmentStabilisationUrgent OT if: amputation for life saving; uncontrollable haemorrhage; open #; severely contaminated wound; ischaemia >6-8hrsFollow Up: repeat XR if initially displaced; may detect # not initially seenRehab?hyperbaric O2: crush injury, compartment syndrome (in RCT setting)

General Fracture

Management

Fat Embolism

Gustilo and Anderson

Open Fracture Classification

Increased risk of infection: contaminated; STI; debridement delay 8hrs; antibiotic delay 3hrs; staph aureus, strep pyogenes, C perfringens, aerobic G-ives if severely contaminated

I <1cm

1-5cm

5-10cm

II

IIIA

>10cmIIIB

IIIC

IV

Clean

Mod contamination

Contaminated

Minimal STI

No extensive STI

Crush injury but adequate cover of bone possible

Simple bone injury

Mod communiution

Crush injury but not adequate coverage

Open fracture with vascular injury; require OT to save limb

Total / subtotal amputation

Affects lungs ( paO2 and CXR changes), cardiovascular, skin (petechiae); occurs in <1% long bone #’s; usually wihtin 6-48hrs of injury; caused by %, CPR, severe burns, liver injury, bone marrow transplant, liposuction; supportive treatment