Fractures
Trauma is commonest cause of death ages 1-44, trauma ~25% of all ER visits. Each death from trauma leaves 3-8 people permanently disabled.
80% low energy (falls etc), 20% high energy (collisions)
Energy imparted to limb
KE = 1/2mv2
Evaluating Possible Fractures
lung, thyroid, renal, breast, prostate
- clinical evaluations
- radiological evaluations
Clinical Evaluations
pain, swelling, deformity, loss of function, crepitus
gait disturbance
soft tissue: open vs closed
examine bones and joints above and below
open fractures
type I: skin wound less than 1 cm - tetanus
type 2: greater than 1 but less than 10 cm - ( +aminoglycocides (ie gentamycin) )
type 3: open wound greater than 6 hours, farm yard (Clostridium), high energy with segmental # or bone loss (+ penicillins)
Radiological Evaluations
get orthogonal views: AP and lateral
soft tissue air, foreign body, swelling
location of fracture
fracture pattern: transverse, spiral, oblique, segmental
simple vs comminuted (multiple pieces)
angulation, displacement, or rotation
CT, bone scans, and MRI can be used.
Fracture Management
ABCs
examine injured part
splint limb
antibiotic/tetanus for open fractures
analgesic
definitive treatment: operative vs nonoperative
appropriate follow-up
rehabilitation - restore strength, motion, proprioreception
Closed Reduction
casts, slings, splints
Operative treatment
Surgical repair should be considered with (peri) articular fracture (risk of OA), vascular injury, floating joints, open fracture, failed closed reduction, and with multiple trauma. Multiple long bone fractures from traumas need to be operatively repaired in order to stabilize people and allow them to be nursed. Compound tissues need to be debrided.
Plates, screws, IM nail device, jusion, joint replacement, or amputation
Fracture healing
There are four stages of fracture healing
inflammation: hematoma, bone necrosis, angiogenesis, PMNS
soft callus: cartilage formation: (clinical union: no pain or movement at # site)
hard callus: cartilage model to woven (immature) bone
remodelling: woven to lamellar (mature) bone - 6-12 months
the more unstable the joint, the more callus is formed.
compund fractures are usually stripped of all tissues, making them dysvascular. Infections thus will be combated slowly.
bone only receives 5% of cardiac output, and so has a difficult time fighting infection.
Complications from Fractures
Life-threatening fractures include pelvic fractures.
earlysoft tissue infection (inc gass gangrene), osteomyelitis, septic arthritis deep vein thrombosis/PE neurovascular injury fat embolism syndrome (ARDS) - pulmonary, cerebral dysfunction/petichiae, especially from long bone fractures |
latepost-traumatic arthritis complex regional pain syndrome (reflex sympathetic dystrophy) delayed union/nonunion/malunion |