2010++DeCoster+Fracture+Principles

8/12/2019 2010++DeCoster+Fracture+Principles

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General Principles of FractureManagement

SWOTA 2010

Thomas A. DeCoster, M.D.

Chief, Division of TraumaVice Chair, Orthopedics

University of New Mexico

President, SWOTA



Which is the clearest description of a

forearm fracture?

• A. Radius and ulna shaft fracture.

• B. BBFA

• C. Fracture of necessity

• D. Piedmont fracture• E. Broken Arm



OUTLINE

• 1 Fracture Definition

• 2 Classification

– OTA

• 3 Healing response

• 4 Common treatments

• 5 Complications



Fracture Definition

• A broken bone



Your fracture pt evaluation

• ER

• Respond quickly and nicely

• Talk to the patient

• EXAMINE the patient

• Review radiograph• Call/notify superior

• Document (pre-op, f/u, etc.)



Fracture evaluation

Clinic• Review current and prior radiographs

• Review prior notes

• Examine the patient

• Identify normal and abnormal healing

• Formulate a plan

– Type and length of immobilization – Return to work

– Analgesia

– Follow-up



Diagnosis

• Physical Exam

– Palpate the bones

– Crepitus

– Related

• Skin

• Neurovascular exam

• X-ray

– Linear radiolucency through bone

– Indirect signs

• What’s the diagnosis in this case?



Correct answer

• Right femur shaft (R32)fracture – Even better

• Wedge Comminution (32-A)

• Transverse (32-A3)

• Middle 1/3 (32-A3.3)

• Right patella fracture (R34) – Insufficient information for further designation

• Incorrect – “broken leg”

– “subtroch” – “femur fracture” (not specific enough-need “Right

femur shaft” to be correct)



Fracture Classification

• Name the bone!!!• Sounds easy, but it’s not

• Then the bone part (proximal, shaft, distal)

for sufficient specificity




General Principles• Group similar injuries

• Separate dissimilar injuries

• IMPROVE communication

• Identify prognosis and complication risk

• DIRECT TREATMENT• Enhance research



Qualities of a good classification

system• All inclusive

• Mutually exclusive

• Reliable

• Reproducible

• Clinically relevant• Logical

• Oxford Textbook of Orthopaedics 2002 DeCoster



Eponyms

• Formerly prevalent

• Fortunately passing into disrepute

• Unfortunately persist as jargon/code

• You need to be aware of them but you do

not need to use them

• Distal radius fracture NOT Colles’ fx




• Name the bone

• Proximal, Shaft or Distal

– Use rule of squares

– Know the exceptions

• OTA/AO 2007 JOT November

• Examples



Fracture classification example

Right femur shaft (R32) p S35

Not distal femur (rule of squares)

Not proximal femur (distal to lesser troch)

Wedge comminution R32-B

Wedge=“butterfly” Not simple (A)

Not complex=segmental comminution (C)



Example 32-B

• Transverse (32-B3)

– Not spiral (B1)

– Not oblique more than 30 degrees (B2) – Less than 30 degrees is transverse (B3)

• Middle zone (32-B3.2) p S37

– Not subtrochanteric zone (.1) – Not distal zone (.3)

– Middle 1/3 OF THE SHAFT (.2)



More examples

• Saturday evening

• Other talks



How do fractures heal?

(one word)



Fracture healing

in a word• CALLUS



Callus

• Fracture healing occurs as mesenchymal cellsdifferentiate and produce progressively stiffermatrix.

• Phases

– Hematoma

– Inflammation

– Callus

• Soft

• Hard

– Re-modelling



Timing of Callus formation in

humans• Hematoma 2 hrs

• Inflammation 2 days

• Soft Callus 2 weeks

• Hard Callus 2 months

• Re-modelling 2 years



Healing strength

• Hematoma 1%

• Inflammation 5%

• Soft callus 25%

• Hard callus 75%

• Re-modelling 110%





Impact of treatment on healing

• Reduce displacement and improve

alignment so that when it heals there is

good function• Stabilization of the fracture allows

mobilization of the patient

• But also many negative impacts



Fracture treatment

• Immobilize the fracture

• Mobilize the patient

• Avoid “fracture disease”

• Avoid complications

• Allow healing



Fracture

Initial Treatment• Splint

• Analgesia

• Elevation

• Follow-up



Fracture Treatment

OPTIONS• Closed

– Non-operative

– Splint

– Cast

– Traction



Fracture Treatment

Options• Operative

– Closed reduction

– Percutaneous pinning

– External fixation

– Internal fixation

– Prosthetic replacement



Internal Fixation

• Open reduction internal fixation ORIF

– Classic plate and screws

– Screws alone (rare)

– Locked plating (recent)



Internal Fixation-Types

• Intramedullary nailing

– Reamed vs. unreamed

– Rigid vs. flexible

– Closed vs. Open

– Locked vs. unlocked

– Statically locked vs. dynamic



Initial Post-op Care-PGY2 issues

• Incision

• Swelling

• Pain

• Elevation

• Patient mobilization



Rehabilitation

• Mobilization of the body part

• Mobilization of the patient

• Progressive weight bearing

– Fixation type

– Healing time



Open Fractures

• Skin is broken

• Infection the big problem

– Closed fx infection rate = 0%

– Open fx infection rate = 20%

• Osteomyelitis is forever



Fractures

Local Complications• Nonunion

Failure to heal

3% overall

50% of some particular fractures

Related to treatment, local problems,

systemic problems (e.g. Smoking)





Nonunion Treatment

• Stabilization

– Hypertrophic Nonunions

– New fixation

• Stimulation

– Atrophic nonunions

– Bone graft

– Other (Estim, ultrasound, BMP)



Malunion

• Healing in poor position

– Crooked = deformity

– Displaced - risk of arthritis





Malunion

Treatment• Prevention

• Straightening

• Salvage



Fracture

Systemic Complications• Fat embolism syndrome

– Marrow elements (fat) released into the

vascular system and travel to the lungs – Triglycerides (fat) metabolized to FFA by

pneumatocytes and these FFS are toxic to tissue

– Especially brain, blood vessels, kidney – ARDS

– Risk of death





Diagnosis of Fat Embolism

• ARDS

• Mental status changes• Petechiae

• Other



Treatment of Fat Embolism

• Respiratory Support

• Early recognition



Systemic complication

DVT/Pulmonary embolism• Fracture leads to immobilization

• Stasis, hypercoagulability, intimal injury

• Thrombosis of LE veins

• Embolism to heart and then lungs

• Mechanical blockage

• Ventilation/perfusion mismatch



DVT/PE

• Respiratory depression

• Cardiac

• Death



DVT Prevention

• Mobilization

– Patient

– Limb• Mechanical

– Skeletal stabilization

– SCD, foot pumps

– Compression

• Chemical anticoagulation



Fractures

Summary• 1. Classification

– OTA 2007

– Name the bone

– Proximal/Shaft/Distal

• 2. Healing Callus

• 3. Treatment options

• 4. Complications

SWOTA 2010



SWOTA : 2010

Resident Course - Fundamentals

of Fracture Care

A) B) C) D) E)

Worst Bad OK Good Best

CLOSED TREATMENT OF FRACTURES

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A) B) C) D) E)

Worst Bad OK Good Best

Quality of Presentation

COMMENTS Please

SWOTA : 2010Resident Course - Fundamentals of Fracture Care

CLOSED TREATMENT OF FRACTURES

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2010++DeCoster+Fracture+Principles