TraumatologyKhaled khalilia th year 4 Khaled khalilia 1) Probability signs of fracture 2) Certainty sign of fracture 3) General complication of fracture 4) Local complication of fracture 5) Non-union: Definition, clinical + radiological signs, symptoms, treatment 6) mal-union: Definition, clinical + radiological signs, symptoms, treatment 7) Delayed union of fracture: Definition, clinical + radiological signs, symptoms, treatment 8) Calice: Steps / stages 9) First-aid in open fracture 10) First-Aid in closed fracture 11) Rules of first-aid in polytrauma 12) Open fracture: Definition, classification and treatment 13) Immobilization (provisional): types of plasters 14) Orthopedic treatment in fracture (e.g. cast, extension, bipolar traction…) 15) General principles of casting 16) Constrictive cast: diagnosis + treatment 17) Functional treatment in fractures (non-OP) 18) Surgical treatment in fractures (e.g. open reduction, internal fixation) 19) Osteosynthesis: material used in treatment of fractures (e.g. screws, pins, nails) 20) Radiological signs in fractures 21) Treatment + Classification for … 22) Diagnosis + Treatment of Sprains and dislocations 1. 22 exam questions 2. X-ray (Radiological anatomy) 3. Original exam x-rays Khaled khalilia 1. Probability signs of fracture: Deformity : is a major difference in the shape of a body part or organ compared to the average shape of that part. Shortening of limb segment Echimosis : The passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin. Pain in fixed point : Shortening of limb segment Deformity Ecchymosis Khaled khalilia 2.tibia): Shoulder Crepitus 1 Interruption to the continuity of the bone Khaled khalilia . rackling or popping sounds and sensations. Certainty sign of fracture: Abnormal mobility: Crepitus: This can be heard when two fragments of a fracture are moved against each other. Loss of mobility: Interruption to the continuity of the bone if it’s a superficial one (clavicle. Khaled khalilia . tachypnea. Immobilization deep vein thrombosis (DVT).or fracture of femoral daiphysis where the hematoma accumulate at the level of the fracture site which produce hypovolemic shock. 3. Prophylaxis very very very very important (lower limb) 6. 2. coma 5. Other disease worsening: Pulmonary complication: Bronchopneumonia. Fat embolism: patients with polytrauma or femoral fracture. Urinary complication: Psychic complication: Latent diabetes. Disturbances in lipid metabolismfree fat acidsacute pulmonary edema. Hypovolemic shock: in fractures with arterial lesion. scintigraphy + marked fibrinogen. General complication of fracture: 1. Neurological signs: irritability. Crush syndrome: appears after a prolonged muscular compression (diagnosis based on renal failure. Signs of embolism are visible 48 hrs after trauma: respiratory failure. pletismography. disorientation. Traumatic shock. MRI. Thromi acute respiratory failzre or sudden death. Diagnosis: venography. Thromboembolism: Disturbances in coagulation deep vein thrombosis (DVT). cyanosis. 4. US. photophobia.3.rhabdomiolysis) .myoglobinuria. Khaled khalilia . Local complication of fracture: ( for more info check the green book(pg. 24-31)) Affecting the Bone: Immediate: contamintation (before the infection) Late/delayed: Infection Hypertrophic callus Delayed union Malunion Nonunion Iterative fracture Aseptic necrosis Affecting soft parts: Immediate: Open fracture Vascular lesion Nervous lesion Interposition of soft parts Compartement syndrome.4. Late/delayed: Pressure sore Volkman syndrome Algodistrophy Affecting joints: Immediate: ligament injurey Late/delayed: instability and arthritis Khaled khalilia . Khaled khalilia . plate or screws. symptoms. Stimulating a new fracture healing response using a bone graft. Cause: Local (90%): error of treatment General (10%): existence of some biological faults connected to poor vascularisation of the tissue upon which consolidation depends. This is accomplished by removal of any poorly dead bone or poorly vascularized tissue or scar from the fracture site. Avascular nonunion: incapable of bio reaction inflammation Treatment: Establishing a healthy vascular area of bone and soft tissue around the fracture site. In some cases a pseudo-joint (pseudarthrosis) develops between the two fragments withcartilage formation and a joint cavity. treatment: definition: the callus formation failed after the maximum period of time when a frature in such site is healing. has a poor blood supply or gets infected.5. Khaled khalilia . This may also involve use of an "external fixator" -.mechanical faults impede the consolidation process to continue. Non-union: Definition. Classification: Hypervascular nonunion: well vascularised. More commonly the tissue between the ununited fragments is scar tissue. Clinical signs: Swelling Pain Tenderness Deformity Difficulty bearing weight x-ray : persistent radiolucent line at the fracture. The normal process of bone healing is interrupted or stalled. clinical + radiological signs. Patients who smoke have a higher incidence of nonunion.external pins to hold the bones above and below the fracture. Nonunion is a serious complication of a fracture and may occur when the fracture moves too much. Establishing stability at the fracture site This usually involves use of a rod. through a small incision at the level of the hip. Callus formation may be evident but callus does not bridge across the fracture.Bone grafts most often involve borrowing healthy cancellous or "spongy" bone from the pelvis. treatment: definition: indicate that a fracture has healed. wrist. plate or screws. This may also involve use of an "external fixator" -.osteotomy or resection Khaled khalilia . A finger that “scissors” onto or away from an adjacent finger Altered use or function of the involved limb. twisted or rotated in a bad position. Malunion may result in a bone being shorter than normal. hand. but that it has healed in less than an optimal position. This is accomplished by removal of any poorly dead bone or poorly vascularized tissue or scar from the fracture site. Clinical signs: Swelling Pain Tenderness Deformity Difficulty bearing weight x-ray : persistent radiolucent line at the fracture. Stimulating a new fracture healing response using a bone graft. Treatment: Establishing a healthy vascular area of bone and soft tissue around the fracture site. or bent. This can happen in almost any bone after fracture and occurs for several reasons. Cause: Local (90%): error of treatment General (10%): existence of some biological faults connected to poor vascularisation of the tissue upon which consolidation depends.6. Correction osteoclasis. or elbow. clinical + radiological signs. Many times all of these deformities are present in the same malunion. Stiffness in finger. Angulation and/or rotation of the fractured bone. mal-union: Definition. symptoms.external pins to hold the bones above and below the fracture. A wrist that does not flex or extend to allow normal use. Establishing stability at the fracture site This usually involves use of a rod. Delayed union is due to: Inadequate blood supply Infection Incorrect splintage Intact fellow bone Clinical signs: Swelling Pain Tenderness Deformity Difficulty bearing weight Fracture site remains tender Bone may still move when stressed On x-ray incipit callus: “cigarette smoke aspect” May be little callus formation or periosteal reaction Cause: Local (90%): error of treatment General (10%): existence of some biological faults connected to poor vascularisation of the tissue upon which consolidation depends. treatment: Definition: Delayed union is the prolongation of time to fracture union there is No definite timetable to define delayed union exists. Delayed union of fracture: Definition. Treatment: Usually continue previous treatment of fracture May need to replace cast or reduce traction Functional bracing promotes bone union For tibial fracture may need to excise portion of fibula It union is delayed more than 6 months may need to consider: Internal fixation Bone grafting Khaled khalilia . clinical + radiological signs.7. symptoms. Calice: Steps / stages: I dunno Khaled khalilia .8. watches. Reduce swelling and pain by applying ice packs on the fracture. Do not attempt to push back the bone that’s sticking out. If the victim has symptoms of shock.First-aid in open fracture: Open fracture is when the fracture site communicates with the exterior through a wound. treat for shock. First aid can be given to open fracture victims to give comfort and alleviate symptoms.com/Treat-an-Open-Fracture-During-First-Aid Khaled khalilia . enroll in First Aid Courses. perform CPR. Clean the wound by thoroughly rinsing it with the disinfected water. If possible. administer oral antibiotics if more than three hours from a hospital.wikihow. Evacuate. If one is trained to apply splint.9. unless it's a wrist or shoulder fracture Clean and dress all wounds Remove tight clothing. More info: http://www. Monitor and treat for shock Give ibuprofen if pain is persistent and there are no signs of shock. To learn more on how to apply first aid on open fractures and other bone injuries. If necessary. If the cloth becomes soaked in blood. Cover the wound with sterile dressing. Immobilize the injured area. do not remove to avoid disturbing the wound. Immobilize the injury.depending how large and dirty the wound is . Check circulation. Skin breaks causing open wound A victim with open fractures should not be moved at all times. sensation and motion beyond the fracture site. Cease the bleeding by applying direct pressure to the wound using any clean absorbent cloth or bandage. Elevate the fracture 6-10" to reduce swelling. First aid should be applied immediately to prevent infections. Ice should not be applied directly to the skin. unless absolutely necessary. Splint the fracture Re-check circulation.using iodine tablets. using an irrigation syringe. Realign the fractured bone. In steps: Asses the fracture. Apply cold packs or ice to the fracture as long as there is no risk of hypothermia or frostbite. sensation and motion beyond the fracture site. apply a splint above and below the fractured area. Disinfect at least a liter of water . Any movement will be very painful and can worsen the injury. jewelry: anything that could impede circulation. Instead. Pads may be added. simply put another cloth on top of the old cloth. com/watch?v=wIFcIjnIsMo Video 2: http://www.com/watch?v=DDYqz8F93kw Khaled khalilia .com/manuals/MILITARY/united_sataes_army_fm_21-11%20%2027_october_1988%20-%20part04. http://pdf.youtube.textfiles.youtube.pdf Video 1: http://www. Decide whether or not to realign the fractured bone. Give ibuprofen if pain is persistent and there are no signs of shock. Evacuate. watches. sensation and motion beyond the fracture site. Proceed with treatment for other injuries.First-Aid in closed fracture: Fractured bone with no break in the skin around it.com/watch?v=9bxCR8a6tPA Khaled khalilia . More info: http://www. Any movement is not only very painful but can worsen the injury. Check circulation. sensation and motion beyond the fracture site. Monitor and treat for shock . as long as there is no risk of hypothermia or frostbite. Elevate the fracture 6 to 10 inches to reduce swelling. Remove tight clothing.youtube. Splint the fracture . and realign if necessary Clean and dress all wounds. Apply cold packs or ice to the fracture. Recheck circulation. Assess for fracture Immobilize the injury.10. jewelry – anything that could impede circulation. youtube. Combination of open/closed fracture and ABCDE-management (check ATI and emergency lectures) Check this pdf: http://www.rmsc.com/watch?v=XIg432xTW8Q (in arabic) Khaled khalilia . which cause the beginning of traumatic disease (wound dystrophy) and need immediate medical aid by life-saving indications.11. Obligatory condition for using of term polytrauma is the occurrence of traumatic shock and life-threatening injury or a combination of such injuries. Rules of first-aid in polytrauma: (not complete) severe multiple and combined injuries.nic.in/RHSDP%20Training%20Modules/Poly%20Trauma_Module.pdf http://www. e.aofoundation.youtube. or fractures that have been open for 8 hr prior to treatment IIIA Type III fracture with adequate periosteal coverage of the fracture bone despite the extensive soft-tissue laceration or damage IIIB Type III fracture with extensive soft-tissue loss and periosteal stripping and bone damage.youtube. wound > 1 cm in length without extensive soft-tissue damage. clean wound. More info: http://www. wound <1 cm in length II Open fracture. fractures requiring vascular repair. Will often need further soft-tissue coverage procedure (i. Usually associated with massive contamination. Open fracture: Definition. irrespective of degree of soft-tissue injury. This type also includes open fractures caused by farm injuries.com/watch?v=_kS9QUfGxmo https://www2. free or rotational flap) IIIC Type III fracture associated with an arterial injury requiring repair. or loss or an open segmental fracture. flaps.12.org/wps/portal/surgery?showPage=redfix&bone=Tibia&segment =Distal&classification=43Special%20considerations&treatment=&method=Special%20considerations&implantstype=P rinciples%20of%20management%20of%20open%20fractures&approach=&redfix_url=13312 87825806&Language=en Treatment: Khaled khalilia .com/watch?v=DDYqz8F93kw http://www. classification and treatment: Gustilo Grade Definition I Open fracture. avulsions III Open fracture with extensive soft-tissue laceration. damage. Wounds are handled only to remove gross contaminants (or to obtain a photographic record and to seal from the environment). Early wound management generally includes the use of antibiotic-impregnated beads and definitive wound closure within 1 week of injury. Immediate surgical exploration is only indicated if there is gross contamination. antibiotics and tetanus prophylaxis are required before surgical treatment. a devascularised limb or if the patient has multiple injuries. Surgical The most important surgical aspect of care in open fractures includes early and complete debridement of non-viable tissue and stabilisation of the fracture. Khaled khalilia . a compartment syndrome developing. ensure healing of the fracture and promote the restoration of function. Associated injuries may be severe and also require urgent treatment. splinting. The treatment of open fractures should be considered as an emergency. Adequate fluid/blood replacement. analgesia. agricultural or sewage contamination.The aims of management are to prevent infection. Start broad spectrum antibiotics (eg IV co-amoxiclav) as soon as possible after injury (certainly within 3 hours). They are no longer "provisionally cleaned" or routinely irrigated. Even as little as a 5-hour delay in debridement is associated with increased infection rates. Open fracture of the distal radius and ulna Gutilo type II open fracture. Debridement is then performed by orthopaedic and plastic surgeons working together on a scheduled trauma list in normal working hours (within 24 hours of the injury) unless there is marine. Khaled khalilia . SHORT ARM CAST: Nondisplaced or minimally displaced fractures of the distal wrist. LONG ARM CAST: Definitive treatment of injuries initially treated with a posterior splint. orbrace will generally extend from the joint above the injury to the joint below the injury. such as fractures . Injuries of the hip and upper thigh orshoulder and upper arm require a cast that encircles the body and extends down the injured leg or arm. nondisplaced. distal fractures of the scaphoid. such as Colles and Smith fractures . an injury to the mid-calf requires immobilizationfrom the knee to the ankle and foot. For example. Splints are also often used for finger injuries. extra-articular fractures of the base of the first metacarpal. THUMB SPICA CAST: Suspected or nondisplaced. hand. nonangulated. This is done to prevent an injured area from moving while it heals.13. isolated malleolar fractures. Lower Extremity and Casts STIRRUP SPLINT: Acute ankle injuries. nondisplaced. leg. the cast. A splint is often used to immobilize a dislocated joint while it heals. RADIAL GUTTER CAST: Definitive or alternative treatment of fractures initially managed with a radial gutter splint. or brace. Immobilization (provisional): types of plasters: Immobilization refers to the process of holding a joint or bone in place witha splint. splint. SHORT LEG CAST: Definitive treatment of injuries to the ankle and foot Khaled khalilia . When an arm. or foot requires immobilization. Upper extremity casts ULNAR GUTTER CAST: Definitive or alternative treatment of injuries commonly treated with ulnar gutter splint.. cast. aafp.http://www.org/afp/2009/0901/afp20090901p491-s1.pdf Khaled khalilia . After surgery on the neck or upper back area. Upper arm. Also used to hold the arm or elbow muscles and tendons in place after surgery. Short leg cast: Applied to the area below the knee to the foot. severe ankle sprains/strains. Also used to hold the leg or foot muscles and tendons in place after surgery to allow healing. Lower leg fractures. Type of Cast Location Uses Shoulder spica cast: Applied around the trunk of the body to the shoulder. Knee. and hand. Minerva cast: Applied around the neck and trunk of the body. Shoulder dislocations or after surgery on the shoulder area. Forearm or wrist fractures. or fractures. or forearm fractures. or lower leg fractures. knee dislocations. Also used to hold the forearm or wrist muscles and tendons in place after surgery. To hold the elbow muscles and tendons in place after a dislocation or surgery. Khaled khalilia . Arm cylinder cast: Applied from the upper arm to the wrist. arm. Long arm cast: Applied from the upper arm to the hand. elbow. or after surgery on the leg or knee area. Leg cylinder cast: Applied from the upper thigh to the ankle.Type of Cast Location Uses Short arm cast: Applied below the elbow to the hand. Sand bagsmanipulation of fractures.14. wiring.33 green book. bipolar traction…): pg. Indicated in undisplaced fractures or in displaced stable fractures. extension.horseshoe. Step1: reduction of the displaced fracture: Anesthesiaremove pain and spasm Reductionextension. Orthopedic treatment in fracture (e.counter extension and manipulation at fracture site. Step 2: immobilization of fracture: With plaster cast. Counter extension inclining the patients bed.g. Khaled khalilia .polleys and weights. Types and versions: Continuous extension Braun-Böhler splint Continuous extensionrieunau type Combining continuous extension + plaster cast Bipolar traction wire transfixing bone above and under the fracture site. Plaster casttight but not constrictiveenclose a joint above and another one below the fracture siteleave fingers uncovered. Step 3: functional recovering The method of continuous traction: Indicated in unstable fractures (when surgery is contraindicated) Reduction done by grafts. cast. html Video 2: http://www. Sheets. up to 20 if big person(increased risk of burn!) Follow up of a cast Immediate post-reduction X Rays Split plaster if any danger of swelling Elevate limb Circulation check 24 hours later More info: video 1: http://suppliescentral. butincreasesrisk of burns • Fastast dryingrn ‐ 5 ‐ 8minutes minutestoto set set • Extra fast‐drying ‐ 2 ‐ 4minutesto set ‐lesstime to mold • Can take up to 1 day to cure (reachmaximumstrength) • Upper extremities ‐ use 8‐10 layers • Lower extremities ‐ 12‐15 layers.youtube.net/instructions.com/watch?v=MH03SsRedWc Khaled khalilia .hold it flexed beforehand Three pressure points are needed to keep reduction These pressure points must not cross a joint Plaster: • Made fromgypsum ‐ calciumsulfate dihydrate • Exothermic reaction when wet ‐recrystallizes (can burn patient) • Warmwater ‐fasterset.15. General principles of casting: (its better to see it on youtube) Indicationsfor Splinting and Casting: • Fractures • Sprains • Jointinfections • Tenosynovitis • Acute arthritis/ gout • Lacerations overjoints • Puncture wounds and animal bites of the hands orfeet Standard Materials and Equipment for Splint and Cast Application Adhesive tape Bandage scissors Basin of water at room temperature Casting gloves Elastic bandage Padding Plaster or fiberglass casting material.use wool such as "Velband" Apply this padding evenly Water must be slightly warm Work the layers to get laminations to bind Never flex a joint after POP is applied .underpads Stockinette Principles of plaster technique: Practice the reduction before cast is applied Pad all fresh fractures . Constrictive cast: diagnosis + treatment: Khaled khalilia .16. youtube. Functional treatment in fractures (non-OP): Its based upon the principle of ignoring the fracture in order to save the patients life.vjortho.com/watch?v=u9A43FyU_dQ Video 3: http://www.17.com/2007/06/functional-treatment-of-fractures/ Video 2: http://www.youtube.com/watch?v=wsGvtipAbU8 Khaled khalilia . The injured may be mobilized without any treatment of the fracture with the price of a noununion or malunion More info: Video 1: http://www. Closed reduction and internal fixation: Orthopedic reduction of the fracture fixation with metallic implants (pains.DCS) External fixator (in open fractures) Open reduction and internal fixation: Invision at fracture site release fractured fragments and fixing them It allows the anatomica reduction (but risk of infection and devascularisation). open reduction. Surgical treatment in fractures (e. nails) without opening the fracture site (under röntgen control). Mimimally invasive ↑↑↑ radiation exposure.18. internal fixation): Indication for surgical treatment: Absolute indication: Irreductible fractures (if we cant do a reduction ) Displaced intra-articular fractures Fractures associated with vascular injury Relative indication: Fractures with secondary displacement Fractures of the sick bone Fractures thatcomplication (if treated by closed methods) Polyfractures Material for fixation: (depend on fracture type): Screws + screwed plates Intramedullary nails Blocked nails Ender nails Locking nails Gamma nails Kirschner wires Blade plates Dynamic screws (DHS. Khaled khalilia .g. Material for fixation: (depend on fracture type): Screws + screwed plates Intramedullary nails Blocked nails Ender nails Locking nails Gamma nails Kirschner wires Blade plates Dynamic screws (DHS. Closed reduction and internal fixation: Orthopedic reduction of the fracture fixation with metallic implants (pains.DCS) DHS + Screws Condylar blade plate External fixator (in open fractures) Open reduction and internal fixation: Invision at fracture site release fractured fragments and fixing them It allows the anatomica reduction (but risk of infection and devascularisation). screws.youtube.com/watch?v=F0VsgxwxxsQ Video 3: http://www. It is a surgical procedure with an open or percutaneous approach to the fractured bone.g.youtube.com/watch?v=GhveGCkAjgM Video 2: http://www. nails): Osteosynthesis is the reduction and fixation of a bone fracture with implantable devices that are usually made of metal. More info: Video 1: http://www.com/watch?v=-kfVeXwNpts Khaled khalilia . nails) without opening the fracture site (under röntgen control). Mimimally invasive ↑↑↑ radiation exposure. In a fracture that is rigidly immobilized the fracture heals by the process of intramembranous ossification. Osteosynthesis aims to bring the fractured bone ends together and immobilize the fracture site while healing takes place.19.youtube. pins. Osteosynthesis: material used in treatment of fractures (e. Harris lines: Colle's fracture: Transverse and partially comminuted fracture of the distal radius Monteggia's fracture : one in the proximal half of the shaft of the ulna. hangman's fracture: fracture through the pedicles of the axis (C2) with or without subluxation of the second cervical vertebra or the third. taking with it a piece of bone. Barton's fracture: fracture of the distal end of the radius into the wrist joint. ping-pong fracture: a type of depressed skull fracture usually seen in young children. Stieda's fracture: fracture of the internal condyle of the femur. the segments of bone not being separated. with dislocation of the head of the radius. Bennett's fracture : fracture of the base of the first metacarpal bone running into the carpometacarpal joint. Le Fort fracture : bilateral horizontal fracture of the maxilla. fat pad sign. complicated by subluxation. with serious injury of the lower tibial articulation.20. sometimes seen in fractures of the skull.: also known as the sail sign suggests an occult fracture. fallen fragment sign : refers to the presence of a bone fragment in the dependent portion of a cystic bone lesion. depressed fracture . Khaled khalilia . depressed skull fracture : fracture of the skull in which a fragment is depressed. greenstick fracture: one in which one side of a bone is broken. Pott's fracture: fracture of the lower part of the fibula. the other being bent. capillary fracture: one that appears on a radiogram as a fine. Radiological signs in fractures: lead pipe fracture : one in which the bone cortex is slightly compressed and bulged on one side with a slight crack on the other side of the bone. or rupture of the medial ligament. Jefferson's fracture: fracture of the atlas (first cervical vertebra). usually a chipping off of a portion of the medial malleolus. hairlike line. silver fork fracture: sprain fracture the separation of a tendon from its insertion. Radiological anatomy: upper extremity: Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Original exam x-ray Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . Khaled khalilia . 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