Clinical Orthopedic
Edited by :
Dr.Soran Mohamad Gharib
2008
Principles of Fracture treatment:-
The fundamental principles of fracture are ( Reduction,
Immobilization and Rehabilitation)
І- Reduction: it is done if (Necessary) ba st there is no need to it, so do it in good (acceptable) alignment i.e out any shortening or overlap or angulation after reduction, so get acceptable alignment and prevent Malunion.
Reduction is necessary only in (displaced or angulated fractures)
- Methods of Reductions: by (manipulation, mechanical traction, open reduction, closed under image intensifier-screen).
1)Manipulation: Manipulation is done in reverse direction i.e if there is internal rotation of fracture do external rotation and if abduction do adduction and it is better to reduced under general anesthesia, by simply grasping in fragment through soft tissue, to disimpact them if necessary, and then to adjust them as nearly as possible to their correct position Occasionally, however reduction is not achieved because of soft tissue interposition or because it is impossible to obtain a sufficient hold on one or other fragments so do open reduction.
2) Mechanical traction: This is used mainly in fracture of femur shaft, because of bulky m. that exerts a strong displacing force. By this we put a traction at tibia or lower end of femur and put wts, and pulley to pull on limb, try to tilt bed, lift foot of bed “so body wt acts as counter traction” .
There are 2 types of mechanical traction
a)Skin Traction: put elastoplast on limb end in cord and we pass a cord on a pulley, and then pull traction by wt. depend on thigh m. skin can not tolerate move than 5 kg.wts.
b)Skeletal traction: because in skin traction we can not use >5kg so if we need more wt, then we insert an instrument “steinmanpin” is inserted (1) inch distal and (1) inch behind tibial tubercle and this is attached to a loop called (sterup) tight loop on a cord is attached at end of cord. If we fail to reduce fracture by these methods then we try 3rd type which is
3) Open (operative) Reduction: In this method surgeon exposes bone-ends and realigns them. This obviously converts a simple (closed) fracture to a compound (opened) fracture is danger of infection and nonunion.
- Indications of open reduction:
1) Soft tissue interposition between two fragments.
2) Failure of conservative method especially spiral fracture.
3) If fracture is inside joint or a piece of bone has been trapped inside Joint.
Once we reduce fracture, we’ve to hold this reduction by immobilization.
П – Immobilization :- Indicated when necessary and indications are :
1) prevention of displacement or angulation.
2) Prevention of movement
3) Relief of pain
* Methods of Immobiliazation:
A) External Fixation: it includes
1) POP ( Plaster of Paris): This is Standard method for most fracture. It is hemi hydrated Ca Sulfate. It reacts with water to form hydrated Ca Sulfate and Liberating heat ( Exothermic reaction).
2) Immobilization by Continuous traction with Splintage: In some POP it is impossible to hold fragments in proper position by pop especially if fracture is oblique or spiral because elastic pull of m. tend to drown distal fragments upwards. So it overlaps proximal fragments. In Such cases pull of m. must be balanced by continuous traction on distal fragment.
3) External fixation –When there is compound comminuted.
B) Internal Fixation: The methods are:
1) Metal plate held by screws as in long bone.
2) Bone graft held by screws: Screws to hold small fragments in place or to hold against redisplacement when overall immobilization is achieved by a plaster Caste
3) Intramedually rods and nails used for fracture of long bones.
4) Oblique Transfixation screws.
5) Suture by wire as in small fracture in epicondyle.
6) Circumferenial wire or band and suture through soft tissue.
7) Closed Femoral nailing and tibial nailing.
8) k wire fixation-post reduction per cutaneous wire.
Indication of external fixation:
1) If fracture is as severe soft tissue damage.
2) If fracture as arterial injury.
3) Severe comminuted fracture.
4) Infected fracture in internal fixation is contra Indic.
5) Severe multiple injuries to reduce risk of complication.
Complications:
1) Loosing of pins (Fixation)
2) Pin tracted infection .
3) Destruct of fracture.
Indications of internal fixation:
1) When closed method impossible as in case of spiral fracture.
2) Poor. bl. Supply as in sub capital fracture of a neck pf femur.
3) Multiple injuries ( as in upper and lower limbs fractures).
4) Pathological fracture ( in order to make life easier and mobilize it ) e.g female breast ca, have metastases to humerus, so by metal bone and cement we do in fixation.
5) When accurate reduction is necessary ( in fracture involving articular surfaces).
6) When early mobilization is needed, especially in old patient-to prevent bed sore, DVT, pull embolism, chest infection.
7) To avoid un-union ( as in sub capital fracture of femur or fracture of scaphoid bone so reduce it and fixed it to avoid non-union.
Complication of internal fixation
1) Infection as wound infection and pull embolism
2) Non-union as a result if poor fixation or poor inetal use.
Rehabilitation
Important factor to all patient
- Resp
- Bowel
- Urinary
- Limbs
Advantage to:
1) reduce oedema
2) Preserve joint movement
3) Restore muscles power
4) Guid the patient to normal activity
Causes of delayed union:
l/infection 2/abnormal or in adequate support
3/0vertraction 4/early mobilization of the Joint
5/inadequate bl. supply. 6/intact follow bone (e.g. fractt. of ^ tibia while the fibula is intact, s.t in this condition we excise a segment from the fibula to promote union)
Causes of non-union:
1/too large gape( excess. traction or b. loss) 2/soft tis.interposit. 3/infection 4/lose of apposition 5/solution of fract. hematoma (synovail fluid washes ^ hematoma preventing union as in fract. Of fem. neck) 6/usage of bad quality metal of int. fix. 7/destruction of b. by turn.
Complications of fracture
They are either general or local complications.
local complication of fractures
1 – Early local complication of fractures
a) bone complications :(infection)
b) * skin complications fract. Blisters)
c) M. complications ( tearing)
d) * Hawmarthrosis :(bl. In ^ j.)
e) Vascular complications : ( complete or partial)
f) N. complications : (cut or pressure)
g) *Visceral damage : (e.g. bladder inj. In pelvic fract.)
2 – late local complication of fractures :
( in bone)
i) Avascular Necrosis : ( Xray appearance)
ii) Delay union : ( causes)
iii) Non- union : (2 types & Rx)
iv) Mal – union
v) Shortening ( growth disturb. & physeal inj.)
(In soft tis *)
i) bed sore
ii) myositis ossificans
iii) tendonitis : ( friction synovitis)
iv) tendon rupture
v) n. compression
(in joints)
i) J. instability
ii) J. stiffness (3 causes ) & 3 conditions:
1 – sudeck’s atrophy
2 – osteoarthrosis
3 – myositis ossificans
General complications of fracture :
I-shock:as a result of ^ fract.shock may occure & it is either :
(a) Neurogenic shock: due to pain. Rx by immobilization either by splintage or tie ^ limb to ^ other one or to ^ chest or truck to avoid mov., also give analgesics (morphine,pethidine )
(b) Hypovolemic shock:^b.is vascular,so damage bleeding
into ^ soft tis. Shock will be ^ result of loss of blood . ( eg.
Closed fract.Of ^ femur IL of blood will be lost inside ^ tis./ more bleeding in pelvic fract. / also even more in
Compound fract.)
II-Crush Syndrome:occurs esp.in comp.fract.& as a result of massive
Damage to ^ m. The acid myohematin is released to bl.Circulation, this
Either causes*blockage to^ renal tubules acute ren.Failure OR causes
* spasm of ^ renal vess. With anoxia of ^ ren. Tis. acute tubular
necrosis.
Crush synd. Occurs also if we leave ^ tourniquet for a long time(>
6hr.). If this happens we should amputate ^ limb before releasing
tourniquet to avoid passage of myohematin into ^ circulation ( so you
should state ^ time of placing ^ tourniq.)
In this synd. We should deal with ^ ren. Failure by decreasing prot.
Intake,increase CHO intake,& do electrolyte balance, high caloric food
& renal dialysis.
III-Venous Thrombosis & Pulmonary Embolism: about 5% of pat. with
DVT will develop pul. Thromboemb., esp in pelvic fract. The
.
IV- Infection: occurs esp. in comp. fract. That may cause osteitis by
Staph.,pseoudomonus, E.coil.This can be Rx by proper AB.
Tetanus: dead tis. Is a good media for growth of Clostridia tetani.
So we need good wound excision & cleaning, & give a booster
Dose of tet. Toxoid.
Management :
Prophylaxis with active imm. Of poplution & use of booster
Dose after injury. Active? Imm. By giving anti - toxin serum of
Human type (horse type not use bec. Of anaphylaxis )
In established tet. Give i.v. fluid balance,& assist ventilation.
Gas gangrene :Clostridia welchii (anaerobic m.o).In this case we
Excise all ^ dead tis.+ debris, so if we receive a wound after 6hr.
Of inj. Or a contaminated wound those should kept open.
Give proper AB C is crystalline penicillin.
If we see dust color,swollen wound with special odour &
Crepitus under ^ skin. We should open ^ wound if it is sutured,
Excise dead tis., give AB,& s.t. hyperbaric O2 is effective.
& if severe infection we have to sacrifice ^ limb by
amputation.
V-Fracture Fever: increase in temp.by 0.50 C as a result of absorption of
Fract. Haematoma.
VI- Fat Embolism: takes place during ^ 1st 3 days. As a result of
Liberation of small fatty molecules in ^ circulation, as chyomicrones C
May be > 10um in diameter pass into ^ general circulation & aggregate
Into cap. & might go to ^ alveoli & pul. Cap. Anoxia.
Clinical orthopedic examination
1.The Back
A) With the patient upright
• Stand Face to face
• Stand behind the patient.
•Movements
B) With the patient prone (remove the pillow)
C) With the patient supine
2.The Hip
With the patient:
( upright, sitting, lying down, In supine position)
3.The Knee
With the patient: upright, Sitting, supine, prone
Nerve examination
[Supply , Inspection , Power .Sensation)
I.Radial Nerve (more motor)
2.Ulnar Nerve
3.Median nerve
4.Femoral nerve (2 cm, has 12 branches) 5.Sciatie nerve (L4,5 & S1, 2,3)
Cervical spine examination
• Inspection, skin, S.C tissue (swelling, scar)
• Feel:
• Movement: (Flexion, Extension , lat. Rotation, lat. Flexion)
• Neurological exam: supply of the upper limb (C5,6,7,8&T1) Examine roots of the nerves by : power, reflex , sensation
The back:
A- with the pateint upright
a- stand face to face
1. Physique and posture.
2. Symmetrical tow sides or not,
3. Scars on the chest or abdomen.
4. Wasting of thigh
b) Stand behind the patient,
1 General Posture and shape.
2. Stand upright or lean to one side.
3. Pelvis level
4. One leg shorter?
5. Hyper kyphosis?
6. Hyper lordosis?
7- scoliosis
8. Scar, hair, lump (spina bifida occulta)
9. Stand on his toes.
10. Stand on his heals.(to assess balance & M.power)
Movements *
1-Extension(hands on trunk & knee straight) - :2. Flexion (look at arc & measure lumbar excursion)
; decreased in Ankylosing spondylitis
3 - Lateral flexion.(slid,his hand dawn) j 4-Rotation,(anchor the pelvis of the pat. In neutral position & ask the pat. To twist to one side then to another side)
B)With the patient prone (remove thepillow)
1. Look for glutei wasting.
2 Feel spinous processes..
(Kyphus=TB of spine or Step= spondylolithesis).
3. Then 3 fingers from midline(artic!ar process& facet J.)
4. Femoral stretch test (pain in ant. thigh).
femoral stretch test :
This is a test for irritation of higher nerve roots - L4 and above.
The patient is positioned lying face downwards, and with the knee flexed, the hip is lifted into extension. Lumbar root irritation tension may cause pain to be felt in the front of the thigh and the back.
5- hamstring power.(feel the M.)
6. Gluteus maximus power. (feel it)
7. Saddle area sensation.(S3&4)
8. Anal reflex. (S4&5)
,9. Popliteal & tibial pulses.
c- with the patient supine:
1-Look for muscle wasting. ,
2. Examine the hip.
3. FABER Test (Hips/Sacroiliac Joints)
FABER stand for Flexion, Abduction, and external Rotation of the hip (and finally press). This test is used to distinguish hip or sacroiliac joint pathology from spine problems.
1. Ask the patient to lie supine on the exam table,
2. Place the foot of the effected side on the opposite knee (this flexes, abducts, and externally rotates the hip).
3. Pain in the groin area indicates a problem with the hip and not the spine,
4. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest
5. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.
FABER test
This is a test for evidence of hip arthritis. In this manoeuvre:
· the patient's pelvis is stabilized by placing a hand on the iliac crest (the side furthest from the examiner).
· the patient flexes his hip joint (the hip joint nearest to the examiner)
· the patient's flexed hip is slowly abducted
If there is early hip osteoarthritis then the abduction of the flexed hip will be restricted and painful. An alternative manoeuvre is to internally rotate the hip with both hip and knee flexed to 90 degrees - internal rotation of the hip joint is the first restriction of movement to occur in hip disease.
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4 straight leg Raising (L5/S1 nerve Roots)
*Ask the patient to lie supine on the exam table with the knees straight
*Grasp the leg near the heel and raise the leg slowly towards the ceiling.
*Pain in an L5 or SI distribution suggests nerve root compression or tension (radicular pain, which may be due to disc prolapse).
• Dorsiflex the foot while maintaining the raised position of the leg
• Increased pain strengthens the likelihood of a nerve root problem.
*Repeat the process with the opposite leg.
* Increased pain on the opposite side indicates that a nerve root problem is almost certain.
Or straight leg raising (SLR) test :
This is a test for lumbosacral nerve root irritation for example, due to disc prolapse.
With the patient laid on their back:
· raise one leg - knee absolutely straight - until pain is experienced in the thigh, buttock and calf
· record angle at which pain occurs - a normal value would be 80-90 degrees - higher in people with ligament laxity
· perform sciatic stretch test - dorsiflex foot at this point of discomfort - test is positive if additional pain results
· flexing the knee will relieve the buttock pain - but this is restored by pressing on the lateral popliteal nerve
Severe root irritation is indicated when straight raising of the leg on the unaffected side produces pain on the affected side. A central disc prolapse is likely with risk to the cauda equina and consequently, of bladder dysfunction.