TBL 1: Orthopedic TBL 1: Orthopedic TraumaTrauma

Husna, Izzati, Ili Safia, Aqilah & Safiyyah

TBL TriggerTBL TriggerA 24 year old man was involved

in a road traffic accident.He was a pedestrian when a

motorcycle knocked him down when he was crossing the road.

Following that incident, he complained of pain of the left leg and was unable to bear weight on his left lower limb.

In A&E, physical examination was performed:◦Revealed swollen, tender and deformed

proximal region of the left leg. ◦No limb threatening injury noted. ◦No wound overlying the deformed

region. An X-ray of the left leg done

reported transverse fracture proximal of the left fibula.

He was admitted to the ward:◦The left leg was elevated on the

Bohler Braun frame awaiting for the swelling to subside and to observe for Compartment syndrome.

◦He was told the fracture is best treated with internal fixation but he opted for conservative treatment.

◦Full leg POP cast was applied after 3 days of admission.

Follow up visit (6 weeks post-trauma):◦X ray was done and it showed no healing

signs.◦The earlier cast was removed and changed

to patellar tendon bearing cast for another six weeks.

Follow up visit (12 weeks post-trauma):◦Revealed mobility to the fracture site –

painless. ◦He was told to have problem with the

fracture healing and needs surgical treatment.

Learning IssuesLearning IssuesAnatomy of the Leg.Fracture – Definition, Classification

and Patterns.Principle of Fracture Management.Acute Complications of Fracture.Process of Fracture Healing.Late Complications of Fracture.Non Union Fracture – Definition,

Classification and Management.

Anatomy of the LegAnatomy of the Leg

i. Bonesii. Muscles

◦ Compartmentsiii. Blood Supplyiv. Nerve Supply

The LegThe Leg

i. Bonesi. Bones

Anterior

Lateral

Fibula

Superficial Posterior

Deep Posterior

Tibia

Tibialis post.

FHLFDL

TA

ELHEDL

PL & B

ii. Muscles and ii. Muscles and compartmentscompartments

Leg compartmentsLeg compartments

Anterior compartment

Walls : i. Interosseous membraneii. Tibiaiii. Fibula

Contents : i. Extensor muscles of the toesii. Anterior tibial arteryiii. Deep peroneal nerveiv. Most susceptible to compartment

syndrome.

Lateral compartment

Walls : i. Fibulaii. Intermuscular septums

Contents: i. Peroneal muscles ii. Superficial peroneal nerve

Superficial Posterior compartment

Walls:i. Transverse intermuscular septum

Contents :i. Gastrocnemius ii.Soleus muscles

Deep Posterior compartment

Walls :i. Transverse intermuscular septumii.Interosseous membrane

Contents: i. Flexor muscles of the footii.Tibial arteryiii.Tibial nerve

Compartments

Muscles Vessels NervesSensory Distributi

on

AnteriorExtensor

muscles of toes

Anterior tibial artery

Deep peroneal

nerve

Web space of first & second

toes

Deep posterior

Deep flexor muscles

Posterior tibial artery

Tibial nerve

Heel

Superficial posterior

Superficial flexor

muscles (gastrocnem

ius and soleus)

LateralPeroneal muscles

Superficial

peroneal nerve

Lateral dorsum of

foot

Summary Summary

Nerve and Nerve and ArteriesArteries

Fracture – Definition, Fracture – Definition, Classification and PatternsClassification and Patterns

Definition of FractureDefinition of Fracture

A break in the structural continuity of bone.

- Apley’s System of Orthopedics & Fractures, 8th Edition

i. Open (Compound) i. Open (Compound) FractureFractureBreakage in the bone that

breaches the skin or one of the body cavities.

Usually due to high-energy injuries e.g. MVA, falls, sports injuries.

Liable to contamination and infection hence require immediate treatment and surgery to clean the area.

Open Fracture Fracture of tibia-fibula with soft-tissue injury

ii. Closed (Simple) ii. Closed (Simple) FractureFractureBreakage in the bone with the

overlying skin still intact.3 types:

◦Compression fracture Occurs when 2 or more bones are

compressed against each other – commonly in the spine bone.

Due to falling in a standing or sitting position, advanced osteoporosis.

◦Avulsion fracture Occurs when a piece of bone is broken off

by a sudden forceful contraction of a muscle.

Common in young athletes.

◦Impacted fracture Occurs when pressure is applied to both

ends of one bone causing it to split into fragments that collide with each other.

Similar to compression fracture, only it is within one bone.

Common in falls and MVA.**View video http://video.about.com/orthopedics/Fractures-2.htm for

better understanding.

Closed fracture

Compression fracture of the spine

Avulsion fracture of the phalanges

Impacted fracture of the femur

Impacted fracture of the tibia

iii. Pathological Fractureiii. Pathological FractureBreakage of bone in an area that is

weakened by another disease process either by:◦Changing the structure i.e. osteoporosis,

Paget’s disease.◦Presence of lytic lesion i.e. bone cyst or

metastasis.◦Infection.

Usually occur during normal daily activities bone unable to withstand even the normal stresses.

Bone cyst resulting in pathological fracture in

the neck of femur

Multiple myeloma of humerus with pathological

fracture

iv. Stress Fractureiv. Stress FractureUsually fractures are caused by

acute, high force to the bone i.e. MVA, fall.

In Stress facture, the force applied is much lower but it happens repetitively for a long period of time.

Rarely occur in the upper extremity because weight bearing is by lower extremity – common site shin and foot.

Contributing factors:◦Athletes

High demand of activity repetitively.

◦Diet abnormalities Poor nutrition e.g. in aneroxia, bulimia.

◦Menstrual irregularities Irregular cycles/amenorrhea signify lack

of estrogen which results in lower bone density.

Common in female athletes.

Stress fractures of the tibia-fibula

i. Incomplete Fracturei. Incomplete FracturePattern Mechanism of

InjuryImages

Hairline fracture-A crack in the bone that does not extend all the way through.

Minor injury e.g. minor fall, minor blunt trauma.

Pattern Mechanism of Injury

Images

Greenstick fracture-Only one side of the bone break resulting in the bone buckling or bending (like snapping a green twig).

-Common in children as bone more springy than adult.

-Similar to this is Plastic deformity – also common in children.

Minor fall, minor blunt trauma.

i. Complete Fracturei. Complete FracturePattern Mechanism of

InjuryImages

Transverse fracture-Fracture straight across the bone.

Tension due to high energy direct trauma.

Pattern Mechanism of Injury

Images

Short Oblique fracture-A fracture which goes at an angle to the axis.

Compression.

Pattern Mechanism of Injury

Images

Spiral fracture-A fracture which runs around the axis of the bone.

-S-shaped.

Twisting.

Pattern Mechanism of Injury

Images

Comminuted fracture-A fracture in which bone is broken, splintered or crushed into a number of pieces.

-A fracture is considered comminuted when there are more than 2 bone fragments.

-Also known as triangular ‘butterfly’ pattern.

Bending.

Pattern Mechanism of Injury

Images

Segmental fracture-A fracture in two parts of the same bone.

- Also known as double fracture.

Severe direct force.

**View video http://video.about.com/orthopedics/Fractures-1.htm for better understanding.

Principles of Fracture Principles of Fracture ManagementManagement

FIRST FIRST GENERAL RESUSCITATIONGENERAL RESUSCITATION

At the HospitalAt the HospitalExamine HEAD TOELevel of consciousness GCSRemember:

Airway

Ensure clear airway

Breathing

Examine chest (atelactasis, pneumothorax)Supplemental O2

ABG if necessary

Circulation

Control bleedingAsses for signs of shockFBC and electrolytes

Secondary Survey

X-rays

Re-evaluation Monitor vital signs

Fractures – Principles of Fractures – Principles of TreatmentTreatment Manipulation – improve position

of fragments. Splintage – hold.

WHILST:

Preserving the joint movement and function – exercise and weight bearing.

Closed Fractures

1. Closed Fractures – REDUCE1. Closed Fractures – REDUCEAim Aim adequate apposition and normal alignment of the adequate apposition and normal alignment of the bone fragmentsbone fragments

Methods:1. Manipulation

- Closed manipulation for minimally displaced fractures- Under anaesthesia and muscle relaxation:1.Distal part is pulled in the line of the bone2.Reposition fragments (reverse original direction of force)3.Adjust alignment

2. Mechanical traction

- Hold the fracture until it starts to unite

3. Open operation

Indications:1.Closed reduction fails2.Large articular fragment3.For avulsion fractures (fragments held apart by muscle pull)4.Operation needed for associated injuries5.When fracture anyhow need internal fixation to hold it

2. Closed Fractures – HOLD 2. Closed Fractures – HOLD Aim Aim splint fracture splint fracture

Methods:1. Sustained traction

- Exert continuous pull in the long axis of the bone- Counterforce needed - Used in spiral fractures of long bone shafts- Types : traction by gravity, balanced traction, fixed traction

2. Cast splintage - E.g Plaster of Paris- Movement restricted- Complications: tight cast(vascular compression, pain), pressure sores, skin abrasions/lacerations (on removal), loose cast

3. Functional bracing

- Use POP or lighter materials while permitting fracture splintage and loading- Joint movements are less restricted- Usually applied only when the fracture is beginning to unite 3-6 weeks

Transfixing pin passes to:Transfixing pin passes to:1. Proximal tibia – hip, thigh 1. Proximal tibia – hip, thigh and knee injuriesand knee injuries2. Distal tibia/calcaneum – 2. Distal tibia/calcaneum – tibial fracturestibial fractures

Balanced skin traction

Braun’s frame

Internal Fixation

Indications:1.Fractures that cannot be reduced except by operation2.Fractures that are unstable (prone to re-displacement)3.Fractures that unite poorly and slowly (e.g femoral neck fracture)4.Pathological fractures5.Multiple fractures6.Patients with nursing difficultiesTypes – screws, wires, plates&screws, intramedullary nailsComplications:(due to poor techniques, poor equipment operating conditions) – infection, non-union, implant failures, refracture

External fixation

Principle – bone is transfixed above and below the fractures with screws/pins/wires which are clamped to a frameIndications:1.Fractures associated with severe soft tissue damage2.Severely comminuted and unstable fractures3.Pelvic fracture4.Fractures a/w nerve or vessel damages5.Infected fractures6.Ununited fracturesComplications:-Damage to soft-tissue structures-Over-distraction-Pin-tract infection

3. Closed Fractures – EXERCISE3. Closed Fractures – EXERCISEAim Aim restore function restore function

1. Prevention of edema2. Active movement/exercise –

stimulate circulation, prevents soft tissue adhesion and promote healing

3. Assisted movement – restore muscle power

4. Functional activity – guide patient in performing normal daily acitivities

Open Open FracturesFractures

Gustilo’s ClassificationGustilo’s Classification

Principles of TreatmentPrinciples of Treatment

Debridement Skin graft

Stabilization

Acute Complications of Acute Complications of FractureFracture

Complications of FractureComplications of Fracture

EARLY LATE

i. Underlying Visceral injury

ii. Vascular injuryiii. Nerve injuryiv. Compartment

syndromev. Haemarthrosisvi. Infectionvii.Gas gangrene

i. Delayed unionii. Malunioniii. Non unioniv. Avascular

necrosisv. Muscle

contracturevi. Joint instabilityvii.Osteoarthritis

i. Underlying Visceral i. Underlying Visceral InjuryInjuryOften in fractures around the trunk.

◦Rib fractures penetration of lung life-threatening pneumothorax .

◦Pelvic fractures rupture of bladder or urethra.

Require emergency treatment, before treating fracture.

ii. Nerve Injuryii. Nerve InjuryCommon in fractures of the humerus,

injuries around elbow & knee.Look for tell tale signs:Closed injuries

◦ Nerve seldom severed wait for spontaneous recovery (90% in 4 months).

◦ Recovery x occur/nerve studies shows no recovery explore nerve.

Open fracture◦ Likely complete nerve lesion.◦ Explore during debridement/secondary

procedure repaired.

iii. Vascular Injuryiii. Vascular InjuryFracture around knee and elbow,

humeral and femoral shafts ↑ ass. w. damage to major artery.

Cut, torn, compressed, contused by initial injury/jagged bone fragments.

N outward appearance intima may be detached, vessel blocked by thrombus, spasm.

Effects vary : transient diminutive of blood flow, profound inchaemia, tissue death, peripheral gangrene.

Clinical featuresParaesthesia /numbness of toes/fingersCold, pale, slightly cyanosed weak/absent

pulseX ray shows high risk fractures

ManagementAngiogramRemove bandages/splintX ray – kinking or compressed reductionReassess circulationNo improvement explore via operation

◦Torn Suture/ replace by vein graft◦Thrombosed endarterectomy to restore

blood flow

iv. Compartment iv. Compartment SyndromeSyndromeA group of conditions that result

from ↑ pressure within a limited anatomic space (limb compartments), acutely compromising the microcirculation and leading to ischaemia of the muscle.

Causes : high risk fractures, infection, operation.

Bleeding, oedema or inflammation↓

↑ Tissue pressures in a compartment↓

Compromise perfusion↓

Tissue hypoxia ↓

Damage to the structures coursing through that compartment (nerves & muscles)

↓Prolonged muscle hypoxia

↓ Necrosis and permanent posttraumatic muscle

contracture (Volkmann's ischemia)

12 hours or less

PathophysiologyPathophysiology

VICIOUS CYCLE OF VOLKMANN’S

ISCHAEMIA

Clinical FeaturesClinical Features Ischaemia (5 Ps):

◦Pain : Earliest symptom bursting sensation

◦Paraesthesia◦Pallor◦Paralysis◦Pulselessness

Muscles sensitive to touch ↑ calf/forearm pain when is hyper-extended.

Pressure of fascial compartment:◦Introduce catheter into compartment measure P close to compartment.

◦Diastolic P – compartment P.◦Differential less than 30 mmHg.

TreatmentTreatmentDecompression

◦Remove bandage, casts, dressings.

Fasciotomy

v. Haemarthrosisv. HaemarthrosisJoint is swollen, tense.Pt resists any attempt to move it.

Aspirate blood first.

vi. Infection vi. Infection Common in open fractures,

unless closed fracture is opened.Chronic osteomyelitis.Slow union, w ↑ chance of re-

fracturingImflamed wound, w seropurulent

discharge.Send for C&S.Start antibiotic.

vii. Gas gangrenevii. Gas gangreneProduced by clostridial infection esp

Clostridum welchii in dirty woundsDestroy cell walls necrosis

spread of diseaseAppear within 24 hours on injuryIntense pain,swelling,brownish

discharge, ↑ HR, characteristic smell, gas formation

Toxaemic coma death

Process of Fracture Process of Fracture HealingHealing

TISSUE DISTRUCTION

AND HEMATOMA FORMATION

INFLAMMATION AND

CELLULAR FORMATION

CALLUS FORMATION

REMODELLING

How Fracture How Fracture Heal?Heal?

Stage 1: start few days after injury and continue for about a month.

Stage 2: starts within a week or two and continues for many months.

Stage 3: continues for many month to a few years.

Fracture Healing Fracture Healing ProcessProcess

Late Complications of Late Complications of FractureFracture

Local ComplicationLocal ComplicationDeformityOsteoarthritis of adjacent /

distant joint Aseptic necrosis Traumatic ChondomalaciaReflex sympathetic dystrophy

Local Complication (cont’)Local Complication (cont’)Contractures Myositis ossificans Avascular necrosis Algodystrophy (or Sudeck's

atrophy) Osteomyelitis

Systemic ComplicationSystemic ComplicationGangreneTetanusSepticemia Fear of mobilizing Osteoarthritis

Non Union Fracture – Non Union Fracture – Definition, Classification Definition, Classification

and Managementand Management

What is mobility to the What is mobility to the fracture site but painless?fracture site but painless?

A sign of non-union (pseudoarthorsis)

Non- UnionNon- UnionThe fracture will never unites

without intervention

Clinical features: Movement can be elicited at the fracture

site Pain diminishes

Causes: Distraction and separation of

fragments Interposition of soft tissues between

the fragments excessive movements at the fracture

site Poor local blood supply Severe damage to soft tissues Infection Abnormal bone

Classification: Hypertrophic (hypervascular) Oligotrophic Atrophic (avascular)

Hypertrophic Non- Union

Features Callus formation initially okayRich of blood supply at the end of fragmentsBut bridging of the fracture gap is failedBone ends are enlarged (X-ray) suggesting osteogenesis Union is still possible if bone fragments are apposed and held immobile

Management Stimulate union:Pulsed electromagnetic fieldLow-frequency pulsed ultrasound

Operative:Rigid fixation (external/internal)

Oligotrophic Non- Union

Features Not hypertrophicCallus is absentHowever there’s intact blood supply Inadequate healing process

Management

Atrophic Non- Union

Features Osteogenesis is ceasedNo sign of attempted bridging Inert and incapable of biologic rxnPoor blood supply to the ends of fragmentsCold bone scanBone ends are tapered or rounded (X-ray)

Management Rigid fixationExcised the sclerotic end of bone ends and the fibrous tissue that filled the gapBone graft around the fracture

Delayed Union Delayed Union The period in which the fracture

is expected to unite and consolidate is prolonged

Causes (as non-union)

Clinical features: Tenderness persists Mobilization at the fracture site

X-ray: Fracture line visible Little callus formation Bone ends not sclerosed or atrophic The appearance suggests the fracture

has not united but eventually will

Treatment:◦Conservatives

Eliminate possible causes of delayed union

Promote healing i.e. immobilization◦Operative

Internal fixator & bone grafting are indicated when there is delayed > 6 months & no sign of callus formation

Take Home Message!Take Home Message!

• Read up the Anatomy!• Fracture – Types and Patterns• Reduce! Hold! Exercise!• Acute and Late Complications• Process of Fracture healing• Non Union Fracture – Classification, Clinical features and Management