Principle of Fracture & Dislocation Management

PRINCIPLE OF FRACTURE AND
DISLOCATION MANAGEMENT
Musculoskeletal module
General Concept of Musculoskeletal Injury
This presentation
General management for trauma
Fracture definition
Fracture management
To study a phenomenon of disease without books is to sail un

uncharted sea, while to study books without patients is not to
go to sea at all
Sir William Osler
Musculoskeletal
Trauma
ATLS (Advanced Trauma Life

Support) : The
Beginning ..................................
....
TREAT PATIENT
AS A WHOLE
HUMAN BEING
NOT PARTIALLY
Initial Managemenet of
Trauma Patient
Primary Survey
Secondary Survey
Concept of Initial
Assessment
Primary Survey
Definitive Care
Adjuncts
Resuscitation
Reevaluation
Reevaluation
Detailed
Secondary Survey
Adjuncts
Initial Assessment &

Management of Trauma Patients
Primary survey and
resuscitation of vital
functions are done
simultaneously in a
team approach
Primary Survey
A
Airway, with C-spine control
B
C
Breathing
The priorities are
the same for all
patients
Circulation,
with hemorrhage control
Disability
Exposure / Environment
Standard Precautions
Cap
Gown
Gloves
Mask
Shoe covers
Goggles / face shield
AIRWAY PROBLEM ?
Airway
obstruction
Solid material
Fluid
Position
Airway Management
Jaw thrust
Orotracheal
intubation
Cricothyroiotomy/
tracheostomy
Primary Survey Breathing
Breathing problems
Hemothoraks
Pneumothoraks
Flail chest +
lung contusion
Primary Survey
Assess and ensure adequate
oxygenation and ventilation
Pitfalls ?
Airway vs ventilation problem ?
Iatrogenic pneumothorax or tension
pneumothorax
Primary Survey Breathing
Needle
thoracocentesis
Chest tube
insertion
CIRCULATION
Hypovolemic shock
PULSE
BLOOD PRESURE
DISORIENTATION
CLAMMY SKIN
Primary Survey
Circulatory
management
Control hemorrhage
Restore volume
Reassess parameters
Primary Survey Circulation

Control bleeding
Direct pressure
Surgical procedure
Vascular access
Peripheral veins
Central vein
Venous cutdown
Intra osseus infusion
Primary Survey
Circulation
Vascular Access
Peripheral vein
infusion
Venous
cutdown
Intraoseus
infusion
MUSCULOSKELETAL PROBLEM IN
PRIMARY SURVEY
A irway
B reathing
C irculation
1. PELVIC FRACTURE
2. FEMORAL FRACTURE
3. MULTIPLE FRACTURE
D isability
E xposure / E nvironment
What is the secondary

survey ?
Head
Posterior
The complete
history and
physical
examination
QuickTime and a
decompressor
are needed to see this picture.
Anterior
Toe
When do I start it ?
After
Primary survey is completed
ABCDEs are reassessed
Vital functions are returning to
normal
What are the

components ?
History : AMPLE
Physical exam : head to toe
Tubes and fingers in every orifices
Complete neurologic exam
Special diagnostic tests
Reevaluation
Secondary Survey History

A llergy
M edication
P ast Medical History
L ast Meal
E vent at Injury
FRACTURE
Structural break in its
continuity, whether its a
bone, an epiphyseal plate
or a cartilaginous joint
surface
Robert Bruce Salter
WHAT IS
Result of single or?
multiple
FRACTURE
mechanical overload on bone

Overload results in
discontinuity of bone
architecture
Happens in miliseconds
Always has soft tissue
damages
FRACTURES CAN
BE
Open vs closed
Complete vs incomplete
Stable vs unstable
Life or limb threatening
Stand alone or part of poly
trauma
Life threatening injuries

- Blood loss
- Fat embolism
- Crush syndrome
100-800
50-400
500-5000
300-2000
100-1000
Limb threatening injuries

Open fractures & joint
injuries
Vascular injuries
Compartment
syndrome
Neurologic injuries
Initial Management
Primary Survey
A irway + C-spine control
B reathing
C irculation + bleeding control
D isability
E xposure
Secondary survey
Initial Management
Immobilization of fracture
Bleeding control
Pain relief
Avoid further complication
Splint early, avoid delay in
resuscitation
Fracture treatments
4R
R ecognition
Diagnose
R eduction
Put it there
R etention
Keep it there
healing
R ehabilitation
Await fx
Recognition
Bony injuries
Clinical findings
Radiological findings
Soft tissue injuries
Clinical Signs of
Fracture
Deformities
Angulation
Shortening
Rotation
Crepitation
False
Movement
Look
Feel
Move
Adequate X-Rays
Fullfill the rule of
2s
2 views (tangential to each other)
2 views (tangential to each other)
2 joints (above and below the fracture)

2 bones (for comparison with other
side)
2 occasions (for comparison, to assess
progress)
Diagnosing soft
tissue injuries
Tissues
Injuries
Skins
Open fx, degloving, ischaemic necrosis
Muscles & tendon
crush, compartment syndrome
Blood vessel
vasospasm, arterial laceration
Nerves
neuropraxia, axonotmesis, neurotmesis
Ligaments
joint instability, dislocation
Soft tissue injuries
Skin & muscle

injury
Ligament
injury
Nerve
injury
Vascular
injury
How to describe a
fracture
Which bone ?
Humerus
Radius / ulna
Femur
Tibia
etc
How to describe a
fracture
Which bone segment ?
Proximal / metaphysis
Middle / diaphysis
Distal / metaphysis
Malleolar segment for distal tibia or fibula
How to describe a fracture

Which fracture type ?
Is the fracture diaphyseal or metaphyseal ?
If metaphyseal part is involved, does the
fracture involve the joint ?
Extra articular
Intra articular

Displacement ?
Tilt / angulation
Shift
Rotation

Displacement ?
Shortening
Angulation
Rotation
Shift
How to describe a
fracture
Displacement
Tilt / angulation
Shift
Rotation
shortening angulation
rotation

Shape
Tibial fracture
Diaphyseal fracture
Comminutive type
fracture
Medial/varus
displacement
Distal radius fracture

Metaphyseal part
Comminutive fracture
Intra articular fracture
Reduction
Manipulation (closed reduction) +
internal/external fixation
Traction
Open Reduction +
internal/external fixation
Anatomical reduction vs functional reduction
Reduction
Anatomical reduction :
intra articular fracture
Functional reduction
Some fractures do not
need to be reduced
Open vs minimal
invasive method
Retention
Non surgical
Sling
Cast (POP or fibrecast) / brace
Traction
Surgical
K-wire
Plate and screw
Intramedullary device
External fixator
Prosthetic replacement
Fracture treatment - Retention
Casting
Sling
Traction
External
Fixator
Internal Fixation
K-wire
DHS
Joint
replacement
IM nail
REHABILITATION
Restoring the patient as close to pre-injury
functional level as possible
May not be possible in certain conditions :
severe fractures or elderly patients
Approach needs to be : pragmatic with
realistic target, and multidisciplinary
Rehabilitation
Rehabilitation : should start as
early as possible
Prevent fracture disease :
stiffness, oedema, muscle atrophy
Passive and active motion (Range
of Motion)
knee CPM
Muscle strengthening
Endurance
NWB, PWB, FWB
CPM = Continuous Passive Movement
elbow CPM
DEFORMITY OF THE
BONE
1.Discontinuity ;
angulation, rotation
2.Bony outgrowth
Abnormal length
STAGES OF FRACTURE
HEALINGSoft callus
Inflammation
Hard callus
Remodelling
hematoma
activated
lamellar bone
medula
bone cel
angiogenesis
angiogenesis
callus
formation
woven bone
restoration
of strength
start bridging
callus
mineralization
reconstituted
56
Conditions that
interfere with
fracture healing
Poor blood supply to the fractured
Poor blood supply to the fractured

area could lead to avascular necrosis
Poor immobilization of fracture site
may cause misalignment or deformity
Infection, more common in open
fractures
DISLOCATION
SEPARATIO
N OF THE
JOINT
Dislocation / Subluxation
Dislocation : bones in a joint
become displaced or misaligned
Subluxation : partial dislocation
Emergency condition
Dislocation / Subluxation
Dislocation
Subluxation
WHAT HAPPENED IF
DISLOCATION OCCURED ?
Vascular injury
Nerve injury
Ligament injury
Associated with
fracture
Soft tissue
entrapment
Dislocation &
Subluxation
Treatment
Initial treatment
Imobilization in position as found

Definitive treatment
Closed reduction, usually with GA
Open reduction, if closed red fail
OPEN FRACTURE
BONE
EXPOSED TO
OUTER
ENVIRONMENT
GUSTILLO & ANDERSON ( 1985 )

Grading of open fractures
GRADE 1
Wound < 1 cm
Usually in-out wound
Simple fracture
Mild-modreate
contamination
Grading of open
fractures
GRADE 2
Wound > 1 cm
Periosteal sleeve
exposed
No soft tissue
avulsion
Short oblique fracture
Moderate
contamination

GRADE 3 A
Periosteal stripped
Soft tissue avulsion but
still adequate coverage
Communitive fracture
Moderate high
contaminated

GRADE 3 B
Periosteal stripped and
no adequate soft tissue
coverage that will
require surgical
coverage
Comminutive fracture
High contaminated
GRADE 3 C
Open fracture with major
artery
disruption
HOW TO TREAT ??
1.Clean the wound

2.Antibiotic based on
culture
Fixed the fracture
Adequate fracture
coverage
COMPARTMENT SYNDROME
Disruption of
distal
extremity
perfussion
cause by
increasing
intracompatm
ent pressure
Compartment
Syndrome
Definition
An increased pressure within enclosed
osteofascial space that reduces capillary
perfussion below level necessary for tissue
viability; the underlying mechanism is :
increased volume within space
decreased space for contents
combination of both
Osteofascial
Compartment
Compartment
Syndrome Diagnosis
History
Clinical examination : 5 Ps
Compartment pressure measurement
Laboratory : CPK, urine myoglobin
Compartment Syndrome
Pain
( passive
strech )
Parestesia
Pallor
Puffiness
Plegi
Pulseless
Compartment Syndrome
Pressure measurement
Whiteside technique
Viscious cycle
Intra
compartme
nt
Pressure
Tissue
Perfusion
edema
Venous
stasis
TREATMENT
CUT THE VISCIOUS CYCLE
1.Release all cast or devices
tightened the extremity
2.Elevation the extremity
Release the pressure by
fasciotomy
Fasciotomy
78
FRACTURE OF UPPER
EXTREMITY
Colles
fracture
Signs of Colles fracture

A
Dorsal
displacement
of distal
fragment
Metaphyseal
area
Styloid ulna
fracture
B
A
C
Defined as :
Fracture through the flare out
disal metaphyses of radius,
with dorsally displaced of
distal fragment followed with
styloid ulna fracture
Abraham Colles ( 1773 1843 )
Treatment
Smith Fracture
Defined as
reverse colles
with distal
fragmen of distal
radius
metaphysis
displaced
anteriorly
FOREARM FRACTURE
Fracture of
diaphysis of
radius and
ulna
Treatment
Closed
Open
GALEAZZI FRACTURE
DISLOCATI
ON
FRACTURE
Defined as :
Fracture of one third
radius diaphysis
associated with
dislocation of distal
radioulnar joint
Treatment
Indication for open
reduction and internal
fixation cause by high
rate of non union
Monteggia fracture
DISLOCATI
ON
FRACTUR
E
Defined as
Fracture of one third
proximal ulna diaphysis
associated with proximal
radioulna dislocation
TREATMENT
OPEN REDUCTION
AND INTERNAL
FIXATION INDICATED
FOR MONTEGGIA
FRACTURE
?
DISLOCATION OF THE ELBOW
EMERGENCY
BEWARE OF NERVE INJURY
BEWARE OF VASCULAR
INJURY
CHECK PULSATION OF RADIAL

AND ULNAR ARTERY !!!
IN CASE OF NO PULSATION :
ONE ATTEMP FOR
REALIGNMENT
IMMOBILIZED
REFER AS SOON AS POSSIBLE
HUMERAL
FRACTURE
FACT IN HUMERAL FRACTURE
90 % CASE HEALED BY NON
OPERATIVE TREATMENT
MOST COMMON SITE FOR
METASTASES AND PRODUCED
PATHOLOGIC FRACTURE
MOST COMMON FRACTURE
ASSOCIATED WITH NERVE INJURY
SHOULDER DISLOCATION
1.Shoulder joint depend its stability on the joint
capsule and surrounding muscle
2.Little bony stability
Most sequela after injury is instability
Most common is anterior dislocation, and
rarely psoterior dislocation
TREATMENT
REDUCTION METHOD
HIPPOCRAT
ES
KOCHER
STIMSON
FRACTURE OF LOWER
EXTREMITY
HIP DISLOCATION
TYPE OF HIP DISLOCATION RELATED

OF POSITION OF FEMORAL HEAD TO
THE ACETABULUM
1.ANTERIOR
DISLOCATION
2.POSTERIOR
DISLOCATION
CENTRAL DISLOCATION
FEMORAL FRACTURE
1. Proximal part
a. Intertrachanter
b. Subtrcochanter
Diaphyseal fracture
a. 1/3 proximal
b. 1/3 middle
c. 1/3 distal
Distal part
a. Condylar
b. Supracondylar
c. Intercondylar
Femoral fracture
treatment
Skin
traction
Locking
plate
Elastic nail
Hemispica
IM nail
Knee dislocation
TIBIA PLATEAU
FRACTURE
ANKLE FRACTURE
PEDIATRIC FRACTURE
NOT A
SMALL
ADULT
WHAT MAKE DIFFERENT ??

1. Fractures more common
2. Stronger and more active
periosteum
3. More rapid fracture healing
4. Specials problem of diagnosis
5.Spontaneous correction of certain
residual deformation
6. Differences in complication
7. Different emphasis on methods of
treatment
8. Torn ligaments and dislocation
less common
9. Less tolerance of major blood loss
If you do not know what

you do not know, its the
end of learning
?
117
Thank You
Danke
Arigato
Gracias
Maturnuwun

Principle of Fracture & Dislocation Management

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PRINCIPLE OF FRACTURE AND

To study a phenomenon of disease without books is to sail un

ATLS (Advanced Trauma Life

Initial Assessment &

Airway, with C-spine control

Primary Survey Breathing

Primary Survey Breathing

Primary Survey Circulation

What is the secondary

What are the

Secondary Survey History

mechanical overload on bone

Life threatening injuries

Limb threatening injuries

2 views (tangential to each other)

2 joints (above and below the fracture)

Open fx, degloving, ischaemic necrosis

Muscles & tendon

crush, compartment syndrome

vasospasm, arterial laceration

neuropraxia, axonotmesis, neurotmesis

joint instability, dislocation

Soft tissue injuries

Skin & muscle

How to describe a fracture

How to describe a fracture

How to describe a fracture

How to describe a fracture

Distal radius fracture

Fracture treatment - Retention

Poor blood supply to the fractured

Imobilization in position as found

GUSTILLO & ANDERSON ( 1985 )

Grading of open fractures

Grading of open fractures

Grading of open fractures

1.Clean the wound

Compartment pressure measurement

Laboratory : CPK, urine myoglobin

Signs of Colles fracture

DISLOCATION OF THE ELBOW

CHECK PULSATION OF RADIAL

TYPE OF HIP DISLOCATION RELATED

WHAT MAKE DIFFERENT ??

If you do not know what

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