PRINCIPLE OF FRACTURES

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* Fracture definition

It is a break in the structural continuity of bone .

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* How fracture happen?

1.from single traumatic incident. 2.repetitive stress . 3.abnormal weakening of the bone (pathological fracture).


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* In cancellous bone trauma produce comminuted crush fracture. Around joint pulling ligament and tendon produce avulsion fracture.


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* How fracture are displaced
By force of the injury. Gravity. By pull of the muscle attached to them.

* How fracture heal

Tissue destruction and haematoma formation. Inflammation and cellular proliferation occurs within 8 hours. clotted haematoma is slowely absorbed and fine capillaries grow into the area then (granulation tissues).


* 3. Callus formation is driven by inductive proteins. 4. Consolidation (woven bone is transformed into lamellar bone) takes several months. 5. Remodelling occurred over a period of months or even years.

* Perkins’ time table

* upper limb . Spiral fracture 3 weeks united * 2 consolidation. Lower limb * 2. Transverse fracture * 2 again.

* In children the time shorter, in elderly longer

* OR THERE MUST BE CLINICAL AND RADIOLOGICAL evidence of consolidation before full stress is permitted without splintage

* CLINICAL FEATURES

History. General sign. Local signs. X-ray. Special imaging.

* history

usually a history of injury ,followed by inability to use the injured limb.BE WARE ……The fracture is not always at the site of the injury, a blow to the knee may fracture the patella ,femoral condyle ,even the acetabulum.

* Pain are common symptom. Bruising ,swelling. Deformity. Numbness, loss of movement. History of previous injury. General medical history.

* General signs

A broken bone is part of a patient so look for .Hemorrhage.Associated damage to brain, spinal cord ,viscera.Predisposing cause (pagets’ disease).

* Local signs

Look : Swelling. Bruising. Deformity. State of the skin.

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* Feel
Tenderness. Distal pulse. sensation.

* Move

Crepitus. Abnormal movement. Movement of the joint distal to the injury.

* Roles of X-RAY to be followed

2 Views
2 Joints
2 Limbs
2 Injuries
2 Occasions
A p & Lateral
Forearm& leg
In Children
Fracture calcaneum
Frcature scaphoid



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* Special imaging

1.TOMOGRAPHY: In spine or tibia condyle injure.

* 2. CT, MRI: In spine fracture which threatened the cord.

* RADIO- ISOTOP scanning: In stress fracture or undisplaced fracture.

* Secondary injuries

Fracture spine cord injure. Fracture pelvis abdominal viscera injuries (intestine, diaphragm, bladder). .



* Fracture ribs lung ,heart .Fracture and dislocation around pectoral girdle: brachial plexuses& vessels.

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* Treatment of closed fracture

General treatment
Treatment of fracture

* General treatmentat the accident site

Air way . Protection cervical spine. Breathing. Bleeding stoppage . by direct pressure or by tourniquets. (time) (Circulation) Fluid replacement

* Examination .Analgesia.Splintage to reduce pain, blood loss…Transport by proper stretcher.

* In the hospital

Rapid survey. Constant re-evaluation. Definitive care.

* treatment of fracture

REDUCE
HOLD
PHYSIOTHERAPY

* Reduction

Conservative (closed). Operative (open).

* Manipulation (reduction)

A: closed reduction: Under anesthesia, with assistant. Used in children fracture, Minimally displaced fracture. Fracture not unstable after reduction.


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* Reduction

B:Open reduction. failure of closed reduction. Displaced intraarticular fracture. Severely displaced avulsion fracture.

* HoldI. Continuous traction

* 1.Traction by the gravity.
For upper limb injure.

* 2.Skin traction

Not more (4-5KG) e.g. fracture in children.


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* 3.Skeletal traction:

By stein Mann pin or Denham pin. >5KG.


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* 4.Fixed traction

In Thomas splint.



* 5.Balanced traction
Over pulleys.

* 6.Combined traction.

* COMPLICATIONSof skin and skeletal
1.may constrict circulation (gallows traction). 2. Nerve injuries (peroneal). 3.compartment syndrome. 4.pin site infection. 5.skin complications.


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* II-cast splintage

Plaster of paris(pop)


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* Complications

1.fracture disease: stiffness, atrophy, osteoporosis, edema. 2.tight cast. 3.pressure sores. 4.Skin laceration

* III-Functional bracing

Is one way of preventing joint stiffness while still permitting fracture splintage and loading. E.g.(fracture femur ,fracture tibia).


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* IV-internal fixation

Screw. Plate . Wire. L-plate. Compression screw. K-nail.

* Indications

Failure conservative. Displaced intra articular fracture. Pathological fracture. Patients who present nursing difficulties.

* Complications

Infection. Non union. Implant failure. Re fracture.


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* V.External fixation(indications)

Fracture with severe soft tissue injuries. Complicated fracture. Infected non union. Fracture pelvis. Multiple injuries. Bone lengthening. Plastic surgery (flap).

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* Over distraction Reduce load transmission. Pin tract infection. Vascular or neurological injury during insertion.
Complications.


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* Prevention of edema: by elevation. Active exercise: So to pump edema fluid and stimulate circulation ,prevent soft tissue adhesion &promotes fracture healing.


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* Assisted movement: By gentle movement only. Functional activity: By improving patient mobility.