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CLINICAL DIAGNOSIS OF FRACTURE AND GENERAL PRINCIPLE OF MANAGEMENT OF FRACTURE
The document outlines the clinical diagnosis and management of fractures, detailing the factors influencing fracture types and symptoms, such as age, mechanism of injury, pain, deformity, and loss of function. It discusses examination methods including inspection, palpation, measurement, and investigations like X-rays, and compares conservative and operative treatment approaches. Additionally, it highlights the classification and management strategies for open fractures and polytrauma cases, emphasizing the need for thorough evaluation and timely intervention.
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Introduction to the presentation on fracture diagnosis by Dr. Manmatha Nayak.
Age and nature of violence are key factors influencing types of fractures, such as epiphyseal separations in children.
Focus on greenstick fractures, commonly seen in children.
Description of various types of fractures based on the mechanism of force applied, including pathological fractures.
Key symptoms in fracture cases include pain, loss of function, and observable deformity or swelling.
Local examination should compare injured and sound side, noting swelling, deformity, and tenderness. Inspection involves checking for abnormal swelling, deformity, skin condition, tenderness, and crepitus.
Measurement of the affected limb should assess longitudinal and circumferential changes compared to the sound limb.
Assess both active and passive movements to determine joint stability post-fracture.
Essential imaging techniques for diagnosing fractures include X-rays, CT scans, and MRI.
Overview of general management principles aimed at restoring anatomy and function after a fracture.
Management strategies for simple fractures include conservative measures and details on closed and open reduction.
Classification and local treatment approaches for open fractures, including emergency care and debridement.
Conclusion of the presentation, thanking the audience for their attention.
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CLINICAL DIAGNOSIS OF FRACTURE AND GENERAL PRINCIPLE OF MANAGEMENT OF FRACTURE
- 1. CLINICAL DIAGNOSIS OF FRACTURE BYDR MANMATHA NAYAK JUNIOR RESIDENT GOVT MC COLLEGE,KOTTAYAM KERALA
- 2. HISTORY • 1) AGE- •Epiphyseal separation – children • Greenstick # - children • Dislocation - adult • Fractures - at any age • 2) THE AMOUNT AND NATURE OF VIOLENCE • How did it occur ?? • Mechanism of force ??
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- 4. • How forcefulwas the injury ?? • * pathological #-violence is not severe enough to cause # femoral neck #- senile osteoporosis subtrochanteric #- pagets dz femoral shaft # - 2ndary carcinoma
- 5. • Nature ofviolence –direct • a) tapping in nature-transverse # • b) crushing – communuted # • -indirect • a) twisting – spiral # • b) bending force-transverse/ oblique # • c)bending +axial compression-butterfly fragment • d)twisting+angulation+axial compression-short oblique # • - muscular
- 7. • Muscle contractsagainst resistance may lead to # • Ex- patella,olecranon ,lesser trochanter of the femur • 3) PAIN- in # pain is felt only during movement of # site • Pain -least in impacted and greenstick # • -unbearable and constant in dislocation • 4) LOSS OF FUNCTION- • Unable to move the fractured limb • He cannt put weight on it • In Dislocation –unable to move the joint even slightly
- 8. • 5)DEFORMITY ORSWELLING • # and dislocation often presents with swelling or deformity
- 9. LOCAL EXAMINATION • Theinjured side should always be compared with sound side
- 10. INSPECTION • 1)ABNORMAL SWELLINGAND DEFORMITY- • Deformity- is due to displaced # fragments • Swelling- is dt hematoma • 2) ATTITUDE- • In certain # patients adopt particular attitude • # NOF – limb externaly rotated • Posterior dislocation of hip- thigh is in flexion ,adduction and internal rotation
- 11. • 3)SHORTENING- • Dtoverlapping of fracture fragments • 4) OVERLYING SKIN- • Skin intact or not??? • Intact- closed # • Not intact -# hematoma communicating to outside-Open# • Edema ,bullae,blebs are quite common dt interference with venous return • Echymosis also appears within a few days after a # or dislocation
- 12. PALPATION • 1)TENDERNESS- • Localbony tenderness is valuable sign of # • Elicited with relation with bone not with the soft tissue • All throughout the length bone is palpated
- 13. • 2)BONY IRREGULARITY- •Whole bone is palpated • To look for any irregularity-such as sharp elevation,gap etc. • Definite sign of # • 3) ABNORMAL MOVEMENT- • This is also definite sign of # • Can be elicited by moving one fragment against other
- 14. • 4) CREPITUS- •It is a sensation of grating which may be felt or heard ,when the bone ends are move against each other • Other condition which produce crepitus- • Ex Hematoma,surgical emphysema,gas gangrene,oa ,tenosynovitis and charcots joint
- 15. • 5) PAINELICITED BY MANIPULATING FROM DISTANCE- • a) by rotating – in case of humerus or femur • b) by squeezing-both bones of leg and forearm • c ) by axial pressure in the line of bone-in metacarpal and metatarsal # • 6) ABSENCE OF TRANSMITTED MOVEMENTS- • Assessed by rotating humerus and femur with flexed elbow or knee respectively by palpating the tubercle of humerus or trochanter of the femur
- 16. • 7) SWELLING- •Characteristic should be noted -wheather bony swelling swelling arises from neighbouring joint ??
- 17. MEASUREMENT • 1)LONGITUDINAL- • Toknow if there is any shortening • 2)CIRCUMFERENTIAL- • To now if there is any wasting dt injury * While taking measurement the sound limb should be kept in the same position as the affected limb * Always good to measure the healthy limb first * measurement should be marked with skin pencil before the use of measuring tape
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- 20. * Measurement shouldbe at the same level in both the limbs in case of circumferencial measurement
- 21. MOVEMENTS • Both activeand passive movement should be tested • Good – no bony or joint injury • Stiffness of the joint is a complication of the # and may be dt- intraarticular and periarticular adhesions,myositits ossification,sudecks osteodystrophy
- 22. INVESTIGATIONS • A) XRAYS- • minimum 2 view • Ap /lateral • Some time oblique and other special views • B)CT SCAN – • C)MRI-too expensive
- 23. GENERAL PRINCIPLES OF MANAGEMENTOF FRACTURE
- 24. GOAL OF FRACTUREM/M • Restore the anatomy back to its normal or as near to normal as possible • There should not be any functional disability to the pt following the treatment of fractures
- 25. MANGEMENT OF SIMPLEFRACTURES • can be managed with conservative or operative methods • A) CONSERVATIVE METHODS • For undisplaced #,incomplete #,impacted # • Cuff and collar sling- for upper limb # • Strapping for # clavicle,finger #,toe # • Pop slab • NSAIDS
- 26. Cuff and collarsling
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- 28. • B)OPERATIVE – •For displaced # • CLOSED REDUCTION OR OPEN REDUCTION • 1)Closed reduction- • Adopted usually for simple frctures • Technique followed is traction and counter traction method • Continous traction is used for reduction of fracture • Ex gallows traction for # sof in children,skeletal traction for adult SOF
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- 31. • Once the# is reduce it has to be retained in position till # unites by pop,continuous traction ,or by using functional brace • Rehabilation is by physiotherapy and exercises once the fracture unitess • 2)Open reduction • Indiacated once the conservative m/m fail or when there are specific indication
- 32. • INDICATIONS- • Absolute-failed closed reduction - displaced intraarticular # -type 3 and 4 epiphyseal injury - major avulsion# - nonunion • Relative -multiple # - for better nursing care -delayed union - to avoid prolong bed rest - loss of reduction
- 33. • METHODS OFOPEN REDUCTION- • After the exposure the # is redued by direct or • indirect methods the # is reduced without exposing by positioning and traction over the fracture table s,skeletal traction etc • PRINCIPLES OF OPEN REDUCTION( by lambotte ) • Exposure-the # is adequately exposed through a proper approach • Reduction of # fragments under direct vision • Temporary stabilization-of the # using k wire done first if necessary
- 34. • Definitive stabilizationusing palte ,screws or intramedullary nails ,k wire ,ss wire etc done later, • Rehabilation process is same as closed mm of fractures • CONTRAINDICATION OF OR- - Infection -small fragments - soft tissue damage - poor general and medical condition
- 36. OPEN FRACTURES • Orthopaedicemergency CLASSIFICATION- 1)GUSTILO AND ANDERSONS TYPE 1- wound <1 cm TYPE II- wound 1- 10 cm, soft tissue normal TYPE III-wound > 10 cm soft tissue are devitalized and contaminated
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- 42. • TYPE IIIA-with extensive soft tissue injury but with adequate soft tissue to cover the # bone • TYPE IIIB-extensive soft tissue damage and loss - bone cannot be covered • TYPE IIIC-with vascular injuries • 2)TSCHERNE CLASIIFICATION • 3)AO CLASSIFICATION
- 43. • APPROACH INOPEN FRACTURES- • General examination-vitals • Examination of other system- • Then examination of open #
- 44. AIMS OF M/M •To convert the contaminated wound into clean wound and thus help to convert an open # into a closed one • To establish union in good position • To prevent infection APPROACH • Stabilise the vital and general condition pt first • Keep the wound covered with proper sterile bandages until the patient is ready for surgery • Open # are surgical emergency and sx to be done once the pt is fit
- 45. • DEBRIDEMENT-consists offollowing steps • Exploration of wound • Excision of all non viable tissue CIrteria to assess tissue viability color –pink –pale consistency-firm-flabby capacity to bleed-+,- contractility-+,-
- 46. • Evacuation-of foreignbodies like dirt,glass,stones,pebbles etc. • Fb are source of infection may invite aforeign body reaction • Hence they hav to be removed by a through irrigation • External fixators are used for fracture fixation after debridement - help to stabilize # fragments - allow daily wound inspection and dressings - permits procedure like ssg for wound covering - allow soft tissue healing and early mobilisation
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- 48. • ANTIBIOTICS ,ANALGESICS,TETANUSPROPHYLAXIS • External fixation can be used as definitive treatment of fracture,or can be removed after 2-3 weeks if soft tissue is healed for definitve procedure like plate ,screw ,interlocking nail etc.
- 49. APPROACH TO APOLYTRAUMA CASE Initial evaluation • A-AIRWay • B-breathing • C-circulation • D- disability • E-Exposure • F-fracture examination • G-go back to the beginning for a2ndary survey • H-help
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