Outline Of Fracture Management & Complication

Outline of Fracture Management & Complication

Presented By: Dr. Md. Taufiq Ul Islam Resident

Fracture • It is a break in the continuity of bone or cartilage. • A fracture is a soft tissue injury with underlying broken bone

Causes of Fracture Fractures may be caused by: 2. A single traumatic event 3. Repetative stress 4. Abnormal weakening of a bone i.e. pathological fracture.

Types of Fracture • Etiologically: Traumatic, Stress or Pathological. • Depending upon fracture pattern: a. Simple: Spiral, Oblique or transverse. b. Wedge: Spiral wedge or bending wedge c. Multifragmentory. • Deformity and displacement: a. Rotation b. Angulation c. Displaced or translation (occurs in two planes) • Associated soft tissue injury: a. Open or closed b. Neurovascular status c. Ligamentous injuries

Biomechanics of Fracture Healing •

The changes associated with fracture healing may be considered as three phases that occur sequentially but may overlap. These are: 2. Phase of inflammation 3. The development of osteogenic repair tissue 4. Phase of remodelling.

Healing of Fracture 1. Fracture & Hematoma 2. Formation of granulation tissue 3. Replacement of granulation tissue by callus 4. Replacement of callus by lamellar bone 5. Remodeling of bone to normal contour

• Reactive phase or phase of inflammation

• Reparative phase

• Remodeling phase

Factors Affecting Fracture Healing • Local Factors: 2. Movement between fracture fragments 3. Extensive damage 4. Surrounding soft tissue injury 5. Interruption of blood supply 6. Infection 7. Interposition of soft tissue in fracture gap 8. Fracture near or including joint 9. Repeated trauma

• 2. 3. 4.

General Factors: Age of the patient General health condition Drugs e.g. Corticosteroids 5. Associated other bone pathology e.g. Osteoporosis 6. Comorbid conditions.

Principles of Fracture Treatment •

Need to consider 2. Reduction 3. Rigid Immobilization 4. Rehabilitation

• Necessity for reduction depends on type of fracture. • Undisplaced vs. displaced fractures. • Closed vs. open reduction.

• Immobilization is always needed until the fracture unites. • Can be done by external or internal methods • External methods include Plaster casts, Tractions and External Fixation. • Internal methods include Plates, Intramedullay Nails, K-wires.

• 2. 3. 4. 5. 6.

Indication for internal fixation: Fracture requiring open reduciton Unstable fracture Intra-articular fractures Pathological fracture Multiple injury patients

• 2. 3. 4.

5.

Indication for external fixation Open fractures Non-union of fracture Filling of segmental limb defects – trauma, tumor and osteomyelitis. Limb lengthening

Advantages • 2. 3. 4. 5.

Internal fixation: Anatomical reduction, absolute stability Allows primary bone healing Earlier mobilization. Early discharge.

• 2. 3. 4.

5.

External fixation: Rapid application Can be applied in acutely injured. Stablizes comminuted fractures that are unstable for ORIF Provides outside # zone fixation for open fractures.

Disadvantages • 2. 3. 4. 5.

Internal fixator: Infection Anaesthetic risk Failure of fixation Malposition of metal work.

•

External fixation: 2. Discomfort for the patient 3. Pin tract infection 4. Failure of fixation.

Management • Management of fracture depends upon the condition of the patient and type of fracture.

Traumatic Fractures

• Diagnose and treat life threatening injuries • Emergency orthopaedic involvement a. Life threatening i. Traumatic amputation ii. Major vascular injury iii. Pelvic fracture disruption iv. Haemorrhage from open fracture v. Multiple long bone fracture vi. Severe crush injury b. Limb threatening i. Vascular injury ii. Major joint dislocation iii. Crush injury iv. Open fractures v. Compartment syndrome vi. Nerve injury

Management of Traumatic Fractures – Emergency orthopaedic management (Day 1) – Monitoring of fracture (Days to weeks) – Rehabilitation + treatment of complications (weeks to months)

Compound Fractures • All open fractures must be assumed to be contaminated • Object of treatment is to prevent them becoming infected • First aid treatment is the same as for a closed fracture • Peripheral neurovascular status should be assessed • In addition the wound should be covered with a sterile dressing • Wound should be photographed so that repeated uncovering is avoided repeated exposure • Antibiotic prophylaxis should be given • Tetanus immunisation status should be evaluated

Management of Compound Fractures. •

Open fractures require early operation • Ideally this should be performed within 6 hours of injury • Aims of surgery are to: o Clean the wound o Remove devitalised tissue o Stabilise the fracture • Small clean wounds can be sutures • Large dirty wounds should be debrided and left open • Debrided wounds can be closed by delayed primary suture ar 5 days

Pathological fracture Generalised bone disease • Osteoporosis • Metabolic bone disease - osteomalacia, hyperparathyroidism • Paget's disease • Myelomatosis Localised benign bone disorder • Chronic infection • Solitary bone cyst • Fibrous cortical defect • Chondroma Primary malignant bone tumours • Osteosarcoma • Chondrosarcoma • Ewing's tumour

Early Complications • 2. 3. 4. 5. 6. 7. 8. 9.

Local Neurovascular injury Visceral injury Haematoma Infection Soft tissue swelling Skin loss Compartment syndrome Neurovascular injury

• 2. 3. 4. 5. 6. 7.

General DIC Hypovolaemic shock Crush injury Atelectesis SIRS Fat embolism.

Late Complications • 2. 3. 4. 5. 6. 7. 8. 9. 10.

Local Delayed union Malunion Non union Joint stiffness OA of joint Pressure sore Contracture AVN Sudek’s atrophy/RSD/ Complex regional pain syndrome 11. Myositis ossificans

• 2. 3. 4. 5. 6.

General DVT PE Disuse atrophy Psychological impact Economic loss

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