Orthopaedic

The Essential
ORTHOPEDIC TRAUMA
 Biomechanics of Fractures

Pelvis

Vm VM
M
m

E ( Energy Kinetic ) = MV 2
 Definition
Emergency :
A situation that involves a potential disabling or life
threatening condition.

Trauma :
A physical wound or injury to living tissue caused by an
extrinsic agent
Fracture : discontinuity of cortex or cartilage
Dislocation : discontinuity of joint
luxation subluxation
Multitrauma : emergency, life threatening more than one
organ requiring immediate treatment intervention
 PRIMARY SURVEY
The ABCDE of muskuloskletal
trauma care identify life
threatening condition.
A. Airway maintenance w/
cervical spine protection
B. Breathing and ventilation
C. Circulation w/ hemorrhage
control, pelvic stability
D. Disability : neurological
status
E. Exposure : completely
undress but prevent
hypothermia life threatening
conditions are identified and
simultaneous management
is instituted
 Pelvic Stability
Anteroposterior
Compression
Lateral
compression
Vertical Shear
 SECONDARY SURVEY
Done after the patient stable

Head to toe !

Every orificiums/ every tubes!!

 How to diagnose the muskuloskletal
trauma problems?
CLINICAL HYSTORY(not for the
multitrauma patients)

PHYSICAL EXAM : LOOK, FEEL,

MOVE,MEASUREMENT

DIAGNOSTIC IMAGING
 FRACTURES

Close fracture Open fracture

Compound fracture
FRACTURES
 DIAGNOSIS

CLINICAL HISTORY (Not for multitrauma pts)

*WHEN (time) : golden periode

*HOW ..MOI (Mechanism of injury : Low

velocity/High velocity trauma/trivial) !!!
 LOOK

Deformity Angulation
- Rotation
- DIscrepancy
Position
Edema
Appearance of the
distal part
Pale
Darken
 FEEL
Crepitation

Temperature of the distal

part
Pulse

Sensory
 MOVE

Active
Passive
Power
False
movement
 MEASUREMENT
MEASUREMENT-
discrepancy
True
length,Anatomical
length
Appearance length
 CLINICAL DIAGNOSIS
Patognomonis sign/definite sign of
fracture: deformity,false movement,

From Clinical History,Physical Exam ,the

clinical diagnosis of fracture is established,

Investigation ( X RAY)important for :

fracture configuration & planning of
definitive treatment , prognosis.
 INVESTIGATION
X-ray (Immobilization first)
2 VIEWS (AP-lateral)
2 JOINTS (proximal & distal)
2 SIDES (IF Necessary)
Special order
Cervical Spine Evaluation
 Pelvic evaluation
7

1. Posterior lip acetabulum

2. Anterior lip acetabulum
3. Dome acetabulum
4. Teardrop
5. Iliopectineal line
6. Ilioischial line
7. SI joint
 OPEN FRACTURES
Open fracture
connection
between the
fracture and the
external
environment
Require emergency
treatment
Significant
morbidity
Principles of Management Open
Fracture

Prevention of infection
Soft tissue healing and bone
union
Restoration of anatomy
Functional recovery

AO Principles of Fracture Management, 2000,

 COMPARTEMENT SYNDROME

Compression of nerve & bloodvessels

Within enclosed anatomic space

(osteofacial)

Leading to impaired bloodflow

 Sign & Symptoms
Classic signs 5 P
Pain
Severe extremity pain out of proportion to
injury
Early sign, worse with passively stretching
involved muscle
Paresthesia
Paralysis
Pulselessness
Pallor
 INDICATION OF CONSULTATION
ALL FRACTURES & DISLOCATION ARE PATOLOGIC
CONDITION.

IMOBILISATION /SPLINT FIRST

STRICTLY NO DELAY OF TRANSFERING PATIENTS W/ FRACT

+ NEUROVASCULAR INJURY, OPEN FRACTURES ,
DISLOCATION.

DO NOT DO HARM
BONE HEALING
Healing of fractures

Bone heal in a slow process, passing

through 5 defined stages:1
Haematoma formation
Cell proliferation
Callus formation
Consolidation
Remodeling
Healing of fractures

* Haematoma formation
* Initially, there is bleeding from the broken bone ends, and the
surrounding soft tissues. This forms a clot or haematoma, which
provides a scaffold for new fiber and bone building cells to move in,
leading to stage two.
Healing of fractures

* Cell proliferation
* The early cells are fibroblasts, arising from the periosteum (a
membrane around the bone). These convert the blood clot to
fibrous material in about 10 days, making the fracture sticky.
The fibroblasts are then replaced by bone building cells called
osteoblasts.
Healing of fractures

* Callus formation
* The osteoblasts start to produce the first bone around the fracture.
At this stage, this begins to appear on an X-ray looking like cotton
wool, and is known as callus. The callus may be felt around the
bone, and the patient will usually notice that the bone is beginning
to feel stronger and less painful.
Healing of fractures

* Consolidation
* Over the next few weeks the callus will harden and consolidate and
the bone will regain its full strength.
Healing of fractures

* Remodeling
* The last stage of the process is the remodeling, when the excess
lump of new bone is removed. This is a slow process, carried out
by cells called osteoclasts. In children, the remodeling is good
enough to remove all trace of the fracture but adults are not so
lucky, so there is often evidence of the fracture in the bone for
many years.
SOFT TISSUE HEALING
 Cardinal Signs of Inflammation

Redness Heat Swelling Pain Loss of

Function
Caused by Increased Caused by Direct injury Increased
dilation of chemical accumulation of nerve pain/ swelling
arterioles/ activity & of blood & fibers,
increased increased damaged tissue pressure of
blood flow blood flow to cells hematoma on n.
skin surface endings
Chemical
irritants
bradykinin,
histamine,
prostaglandin
 Phase I: Acute Inflammatory Phase

Substrate Phase
Begins almost right away, lasts approx. 2-4 days
Goal
Protect,
Localize,
Decrease injurious agents,
Prepare for healing and repair
Critical to the healing processes - If this phase does not
accomplish what it is supposed to or if it does not
subside, normal healing cannot take place.
Lasts until damaged tissue has been removed & new
capillary network has been formed
 Phase II: Proliferation/Fibroblastic
Phase
Repair/Regeneration or Fibroblastic phase

Phase will extend from 48 hours to 3-6 weeks

Phase removes debris & temporary repair SCAR

FORMATION (fibroplasia)

Adenosine triphosphate (ATP) is a critical factor that

regulates the rate & quality of healing
- cells primary source of energy
- provides metabolism needed to restore cells membrane
properties by moving Na2+ & K+ into & out of cell, to build new
proteins & synthesize proteins
 Phase III: Remodeling/Regeneration/
Maturation Phase
Usually begins @ week 3
Purpose is to increase strength of repaired/replaced
tissues
First 3-6 weeks involves laying down of collagen and strengthening of
fibers
3 months to 2 years allowed for enhanced scar tissue strength
 Principles of treatment
RICE
Rest, Ice, Compression, Elevation