Basic Care of Common Fractures Utku Kandemir, MD

Transcription

1 Basic Care of Common Fractures Utku Kandemir, MD Assistant Clinical Professor Trauma & Sports Medicine Dept. of Orthopaedic Surgery UCSF / SFGH

2 History Physical Exam Radiology Treatment

3 History Acute trauma vs. repetitive trauma vs. no trauma Mechanism of Injury Direct vs. Indirect Force High energy vs. Low energy Past Medical & Surgical History Stress fx,, Occult fx, osteopenia/osteoporosis, RA, Steroid use

4 Physical Examination Inspection Deformity, swelling, ecchymosis,, open wound Active ROM Palpation / Passive ROM Neurovascular Examination Compartment syndrome: <4 hrs - >8 hrs

5 Compartment Syndrome -Definition Increased pressure within an osseofascial compartment reducing perfusion gradient across tissue capillary beds leading to cellular anoxia and death (muscles & nerves)

6 Compartment Syndrome -Etiology Fracture Soft tissue injury Bleeding disorders Tight cast, dressing, external wrapping Arterial injury Burn Long-lasting limb compression (drug overdose etc.) Extravasation of intravenous infusion Reperfusion injury Penetrating trauma

7 Compartment Syndrome -Diagnosis Clinical +/- Compartment pressure measurements Swelling Tense/Firm compartment Pain out of proportion regarding severity of the injury Pain aggravated with passive stretch Neurologic deficit Sensory (hypoesthesia, paraesthesia ) Motor (paresis, paralysis

8 Compartment Syndrome -Treatment Emergency Fasciotomies

9 Radiology X-ray Order Include the joint above and below No less than 2 views: AP & Lateral Comparative views in skeletally immature

10 Radiology Reading x-raysx Location of fracture (1/3) Proximal, Middle, Distal Intra- vs. Extra articular Displacement Angulation,, Translation, Shortening, Distraction, Rotation Pattern Transverse, Oblique, Spiral, Comminuted, Segmental Pediatric Torus/buckle, Greenstick, Physeal

11 Location of fracture (1/3) Proximal, Middle, Distal Radiology Proximal 1/3 Middle 1/3 Distal 1/3 Proximal 1/3 Middle 1/3 Junction Middle 1/3 Distal 1/3 Junction

12 Location of fracture Intra- vs. Extra articular Radiology

13 Radiology Angulation: α degrees APEX anterior/posterior, medial/lateral α Medial Lateral

14 Radiology Shortening / Overlap, Distraction

15 Radiology Translation 1 2

16 Rotation Radiology

17 Radiology Intraarticular displacement: gap, step-off

18 Pediatric Radiology Physeal, Torus/buckle, Greenstick

19 Fractures vs. Dislocations Reduction of Dislocation is NECESSARY acutely Fracture dislocations needs to be seen by Orthopaedics urgently Fractures may be splinted as far as neurovascularly intact, grossly aligned, no risk of further soft tissue injury Dislocation: no contact of articular surfaces

20 Initial Treatment When in doubt about fracture Immobilize Inform the patient about the possibility of a fracture (nondisplaced fxs,, some fractures may not be apparent up to 2 weeks e.g. scaphoid) Arrange follow up with an orthopaedic surgeon

21 Initial Treatment Immobilization (splinting, bracing) Rest (NWB) Cold (Ice packs) Limits hemorrhage and edema, increases pain threshold min q4hrs (frosbite( injury!) Elevation Pain control

22 Splinting/Bracing Immobilization of fracture, sprain, soft tissue injury Prevent further soft tissue injury (neurovascular, musculotendinous,, skin) Pain control Reduction of edema Maintains bony alignment

23 Splinting/Bracing Plaster of Paris or Fiberglass Advantage over casting: Allows continued swelling avoid complication: compartment syndrome

24 Splinting/Bracing Remove all clothing and constrictive devices from extremity (jewelry, rings) Align severely angulated fracture alleviates acute pain, relieves blood vessel and nerve tension, and may restore circulation to a pulseless extremity Apply padding (cotton), Protect bony prominences Assess neurovascular status immediately before and after splinting and DOCUMENT If periodic wound care is required / relatively stable fracture consider a removable splint

25 Emergency / Urgency Unreduceable dislocation Neurovascular deficit (before OR after reduction/splinting) Open fracture/ Impending open fracture

26 Risk Management Always document neurovascular status before and after splint application, fracture or joint reduction Remove all rings on hands/toes before splint application Clearly document follow-up instructions: with whom when to see orthopedic surgeon when to return to the emergency department

27 Arm sling / Clavicle support Urgent Clavicle Fracture Open Neurovascular injury Tenting skin (impending open)

28 Proximal Humerus Fractures AP, Axillary view, Y view

29 Proximal Humerus Fractures AP, Axillary view view,, Y view Confirm that the GH joint is reduced or not

30 Proximal Humerus Fractures AP, Axillary view view,, Y view Confirm that the GH joint is reduced

31 Proximal Humerus Fractures AP, Axillary view, Y view

32 Proximal Humerus Fractures Neurovascular exam: Axillary nerve (dermatome: proximal 1/3 lateral arm) Brachial plexus

33 Proximal Humerus Fractures Acute care: Shoulder immobilizer Arm sling

34 Humerus Shaft Fractures Midshaft: : Radial Nerve! Definitive treatment Mostly nonoperative

35 Humerus Shaft Fractures Acute Care: Arm sugar tong splint /Shoulder immobilizer

36 Elbow (Distal Humerus, Olecranon) Make sure that the joint is not dislocated Long arm splint at 45 degrees Definitive treatment Mostly surgical

37 Radial Head Fractures Tenderness at lateral elbow, pain with pronation/supination, Check Wrist (DRUJ) Long arm splint at 90 degrees

38 Forearm fractures Compartment syndrome Long Arm Splint Definitive treatment Surgery in adults, >10 yrs old

39 Distal Radius Fractures Short arm / Sugar tong splint Leave MCP joints mobile ELEVATION

40 Scaphoid fractures Snuffbox tenderness Fracture may not be visible first couple weeks Thumb splint/ thumb gutter splint

41 Metacarpal fractures Short Arm Splint extending to the tip of fingers Ulnar Gutter for 5 th MC neck fx

42 Finger fractures Nailbed hematoma Aluminum splint &/ taping to the next finger

43 Metatarsal Fractures Short Leg Splint/ Lower Leg Walker

44 Ankle Fracture AP, Lateral, Mortise views Make sure the joint is reduced after reduction Short leg splint / Lower leg walker

45 Ankle Fracture

46 Tibia Plateau Fracture Swollen knee ROM Acute Tx: NWB Knee immobilizer

47 Patella Fracture Swollen knee Loss of active extension

48 Thank you Phone: (415) Fax: (415)