6-Fractures and Joints Dislocations Management
6-Fractures and Joints Dislocations Management
6-Fractures and Joints Dislocations Management
DISLOCATIONS MANAGEMENT
Dr. BAYISENGA Justin, MD, MMed, SURGERY
Senior Consultant General Surgeon
July 2023
INTRODUCTION
• Fractures and dislocations are mostlty caused
by high energy trauma.
• High energy trauma is a major cause of
mortality among young citizens worldwide.
• Injury is the leading cause of death under the
age of 40 (USA)
• The cost is also high to cure extremities
injuries.
Fracture healing
It can be conveniently divided, based on the
biologic events taking place, into the following
four stages
1. Hematoma formation (inflammation) and
angiogenesis.
2. Cartilage formation with subsequent
calcification
3. Cartilage removal and bone formation
4. Bone remodeling
Orthopedic Assessment & Management of
Polytrauma Patients
Life-Threatening Conditions: The ABCs of Trauma Care
• A systematic approach is required in all cases.
• The patient is assessed and treatment priorities are
established according to the type of injury, stability
of vital signs, and mechanism of injury.
• In a severely injured patient, treatment priorities are
dictated by the patient's overall condition, with the
first goal being to save life and preserve the major
functions of the body.
Assessment consists of four
overlapping phases:
1. Primary survey (ABCDE)
2. Resuscitation
3. Secondary survey (head-to-toe evaluation and
history taking)
4. Definitive care
Primary survey
• Airway maintenance (with cervical spine
protection);
• Breathing and ventilation;
• Circulation (with hemorrhage control);
Disability (neurologic status);
• Exposure and environmental control (undress
the patient but prevent hypothermia).
A: Airway + C-spine protection
• The airway should be rapidly assessed for signs of
obstruction, foreign bodies and facial, mandibular, or
tracheal/laryngeal fractures.
• A chin lift or jaw thrust maneuver should be used to
establish an airway.
• A Glasgow Coma Scale of 8 or less is an indication
for the placement of a definitive airway (Intubation)
• Any patient with a blunt injury above the clavicle
should be considered at risk for cervical spine injury).
B: Breathing + Oxygenotherapy
• The surgeon should evaluate the patient's chest.
• Adequate ventilation requires not only airway patency
but also adequate oxygenation and carbon dioxide
elimination.
• If any breathing problem on trauma patient think
about:
1. Tension pneumothorax
2. Flail chest with pulmonary contusion
3. Open pneumothorax and
4. Massive hemothorax.
C: Circulation
• Hemorrhage is the principal cause of post injury
deaths that are preventable.
• Level of consciousness, skin color and pulses are
simple to assess the hemodynamic status of the
patient, especially if recorded serially.
Pay attention on fractures because they can cause
major blood loss and severely compromise the
ultimate survival of the patient:
• Fractures of the femur (blood loss of 1.5 to 2l)
• Pelvic fracture (blood loss of 2to 3l).
D: Disability (Neurologic Status)
• Glasgow Coma Scale should be used to assess
neurologic status.
• A simpler way to monitor central neurologic
status is to remember the mnemonic AVPU
and check if the patient is:
• Alert
• Verbal response
• Pain response
• Unresponsive
E: Exposure and Environmental
Control
• Recognition of lacerations, contusions,
abrasions, swelling and deformity can only be
accomplished in the completely disrobed
patient.
• Hypothermia must be avoided.
• Sterile dressings should be applied to any
wounds and wound exploration in the
emergency department should be avoided to
prevent further contamination.
Care of Patient before
Hospitalization
• Recognition and appropriate splinting of
major fractures, adequate immobilization of
the cervical spine, and proper handling of the
injured patient are essential to prevent
further damage to the neurovascular
elements and limit hemorrhage.
• Proper care at this stage will prevent or limit
shock as well as avoid catastrophic damage to
the spinal cord.
General rule:
The following measures should be taken
managing fractures or joints dislocations:
1. The joints above and below the fracture should be immobilized.
2. Splints can be improvised with pillows, blankets, or clothing.
3. Immobilization does not need to be absolutely rigid.
4. Apply gentle in-line traction to realign the extremity in severe
angulation.
5. Overt bleeding should be tamponaded with available dressings
and firm pressure.
6. Tourniquets should be avoided, unless it is obvious that the
patient's life is in danger.
GENERAL PRINCIPLES OF
FRACTURES MANAGEMENT
Introduction and Definitions
Fracture is disruption of bone continuity
Most of fractures occur as a result of a single
episode by a force powerful enough to
fracture a normal bone
Pathological fracture: is one in which a bone
is broken through an area weakened by pre-
existing disease , & by a degree of force that
would have left normal bone intact like
osteoporosis , Osteomyelitis, bone tumors.
Introduction and Definitions
Stress fracture: Bone , like other materials ,
reacts to repeated loading .
On occasion , it becomes fatigued & a crack
develops e.g. military installations , ballet
dancers & athletes.
Introduction and Definitions
Other types of fractures
Introduction and Definitions
Introduction and Definitions
Greenstick fracture-occurs in children.
Stress fracture- common in athletes.
Fatigue fracture- in occupation like police
Pathological fractures-usually seen in elderly.
Introduction and Definitions
Description of a fracture
Which bone is injured
The region of the bone injured
Is the fracture simple or multifragmentary?
The direction of the fracture line: transverse,
oblique or spiral
Introduction and Definitions
Displaced or undisplaced?
Angulation?
Rotation?
Shortening
Alignment, length and rotation
Any evidence of pre-existing pathology?
Introduction and Definitions
Seven sign of fracture
Tenderness
Swelling and Ecchymosis
Deformity
Crepitus
Exposed fragment
False Motion
Inability to Use the Limb
Introduction and Definitions
• Fractures may be classified into open and
closed
For open Fractures, Gustilo & Anderson
Classification is used
For closed fractures there are multiple
classifications especially according to the
location of fractures.
Management of fracture
Goals
Restore the patient to optimal functional
state;
Prevent fracture and soft-tissue
complications;
Get the fracture to heal, and in a position
which will produce optimal functional
recovery;
Rehabilitate the patient as early as possible.
Management of fracture
Uncomplicated closed fracture
Three fundamental principles of fracture
treatment
Reduction
Immobilization
Preservation of function
1. Reduction
• Can be done by:
Closed manipulation
Mechanical traction with or without
manipulation
Open reduction and internal fixation (ORIF)
Reduction
Manipulative reduction
the standard initial method of reducing most
common fractures.
The technique is simply to grasp the
fragments through the soft tissues, to
disimpact them if necessary, then to adjust
them as nearly as possible to their correct
position
Reduction
Reduction by mechanical traction
When the contraction of large muscles exerts a
strong displacing force, some mechanical aid may
be necessary to draw the fragments out to the
normal length of the bone,
Traction may be applied either by weights or by a
screw device,
This particularly applies to fractures of the shaft
of the femur, and to certain types of fracture or
displacement of the cervical spine.
Reduction
Operative reduction
When an acceptable reduction cannot be
obtained, or maintained,
Open reduction may be required for some
fractures involving articular surfaces, or when
the fracture is complicated by damage to a
nerve or artery.
Success by open reduction depends on :
Proper indication
Proper timing
Proper Surgical approach
Proper technique
Proper selection of implant
Proper Surgeon
2. Immobilization
Indications
To prevent displacement or angulation of the
fragments
To prevent movement that might interfere with
union
To relieve pain.
Can be achieved by
plaster of Paris cast or other external splint
continuous traction
external fixation
internal fixation
A. Immobilization by plaster, splint or
brace
For most fractures the but except in a few
standard method of developing countries, most
immobilization is by a hospitals now use ready-
plaster of Paris cast made proprietary
Plaster technique bandages.
Plaster of Paris is These are best used with
hemihydrated calcium cold water because setting
sulphate. It reacts with is too rapid with warm
water to form hydrated water
calcium sulphate
Plaster bandages may be
prepared by impregnating
rolls of book muslin with
the dry powdered plaster
The plaster bandages are applied in two forms:
round-and-round bandages and longitudinal
strips or ‘slabs’ to reinforce a particular area
Round-and round bandages must be applied
smoothly without tension, the material being
drawn out to its full width at each turn.
Slabs are prepared by unrolling a bandage to and
fro upon a table: an average slab consists of
about 12 thicknesses.
The slabs are placed at points of weakness or
stress and are held in place by further turns of
plaster bandage.
A plaster is best dried simply by exposure to
the air: artificial heating is unnecessary. A
plaster will not dry satisfactorily if it is kept
covered by clothing or bed-linen.
B. Continuous skeletal traction
C. External fixation
Indications
Acute trauma - open and unstable fractures
Non union of fractures
Arthrodesis
Correction of joint contracture
Filling of segmental limb defects
Limb lengthening
Contraindications
Absolute : Relative :
Polytrauma Loss of position with closed
method,
Displaced intra-
Poor functional result with
articular fractures non-anatomical reduction,
Open #’s Displaced fractures with
#’s with vascular poor blood supply,
injury or Economic and medical
compartment syn, indications
Pathological #’s
Non-unions
Methods
Metal plate held by screws or locking plate (with
screws fixed to the plate by threaded holes)
Intramedullary nail, with or without cross-screw
fixation for locking
Dynamic compression screw-plate
Condylar screw-plate
Tension band wiring
Transfixion screws
How do fracture heal in nature?
1) Reactivephase
– Fracture and inflammatory phase
– Granulation tissue formation
2) Reparative phase
– Callus formation
– Lamellar bone deposition
3) Remodelling phase
– Remodelling to original bone contour
Fracture healing in nature
1. Reactive phase Cell division begins
Bone ends bleeds within 8 hours following
Haematoma formation release of vasoactive
mediators, growth
Periosteum is stripped factors and other
for variable length cytokines eg. BMP, TGF-
Surrounding soft tissue B, PDGF, FGF, IGF-II, IL-
may be damaged 1, IL-6
Acute inflammation Cell proliferation seen
within periosteum
Fracture healing in nature
2. Reparative phase Amount of callus formed
Vasoactive substances directly proportional to
(NO and ESAF) causes amount of movement at
neovascularisation & local fracture site
vasodilatation Dead bone resorbed and
Mesenchymal cells immature woven bone
migrate and form laid down
chondrogenic,osteogenic
and fibrous tissue Consolidation – Woven
Fracture haematoma bone and hyaline
organized and Type II cartilage is replaced by
collagen laid down lamellar bone
Fracture becomes united
Fracture healing in nature
3. Remodelling
Phase of remodelling
Medullary cavity is
restored
Bone returns to normal
shape
How do fractures heal when
operated?
1) Reduction and compression
Primary bone healing
Slow process, rehabilitation rapid, high risk