General Surgery Sheet #10 By Sari Mahasneh

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General Surgery Sheet #10 By Sari Mahasneh

Post by Sura on 28/4/2012, 9:51 pm

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تاريخ التسجيل : 2010-09-29

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Re: General Surgery Sheet #10 By Sari Mahasneh

Post by Shadi Jarrar on 5/5/2012, 3:20 pm

Bone Fractures

Today we will be talking about bone fractures, principles and management.
Statistics shows that 60 million people/year suffer from trauma
50% of them need to be seen by an MD or a professional.
12% need admission to the hospital
9% end up with a disability at least for 24 hours
150000 are disabled permanently
Cost of management of these patients is around 400 billion dollars/year

Always remember that no patient die because he has a fracture. However, they die because of fracture complications (i.e. complications around the fracture site)
e.g. if a patient has a fractured maxilla he won't die because of the fracture itself but because of the injuries that might happen due to the fracture such as brain injury, eye injury, airway, etc.
So the main purpose in treating these patients is to save their lives and not to be concentrated at the trauma site and ignore the other complications.
So the priorities are:
1. Save their life
2. Take care of the skin
3. treat the fracture
Trauma is the leading cause of death for the patients who are younger than 40 years of age
Trauma can be caused by road traffic accident, fallen down, etc.
As I said before trauma isn't about bone fracture alone but it includes soft tissues which may be damaged (e.g. arteries, veins and nerves).
In general, trauma can be classified into 3 main categories:
1. fracture
2. dislocation of a joint
3. dislocation accompanied by a fracture (usually the fracture is around the joint)
Magnitude of trauma needed to cause the dislocation is higher than that needed to cause the fracture and lower than that needed to cause both dislocation and fracture.
A fracture is defined as the disruption of the continuity of the bone by whatever cause.
Dislocation is defined as disruption of the normal articulation of the joint and it could be complete or incomplete.
Incomplete also called subluxation is the partial contact of bones at the joint area.
In the knee if the tibia and the femur are partially contact (touching) this is called incomplete/ subluxation while if there is complete loss of contact then it's called complete dislocation

Subluxation knee Complete Knee dislocation

Classification of fractures:
They are classified for several purposes which include:
1. to be able to differentiate the types of fractures and thus their prognosis
2. as a universal way of communication between doctors
We have 2 main ways for the classifications of fractures:
1. the mechanism of trauma
2. the shape of the fracture
I will start with the mechanism of trauma:
If the applied force (trauma) is higher in magnitude the force that the bone can withstand then the bone will fracture and it's called traumatic fracture, e.g. trauma caused by a car accident or trauma caused by falling form a height of 10m.
If the applied force is lower in magnitude than the force that the normal bone can withstand and the bone was fractured then it's called pathologic fracture because there is an underlying pathology in the bone, e.g. fracture of bone while handshaking.
If the applied force was minor and repetitive it will end up with bone fracture and its called stress fracture, e.g. soldiers with their daily marching will end up with fractures because of the minor, simple and repetitive micro trauma, ballet dancing girls, basketball and soccer players.
So the mechanism of trauma classification is divided into:
1. traumatic fracture
2. pathologic fracture
3. stress fracture


The other classification which depends on the shape of the fracture includes:
1. transverse: the diameter of the fracture equals the diameter of the bone
2. spiral: the diameter of the fracture equals double the diameter of the bone
3. oblique

The comminuted bone fracture is a fracture at which the bone has broken into a number of pieces.

The dr. is talking about picture of soccer players who developed fractures and in this case it's called traumatic fracture
Another picture of a lady who was walking and heard a fracture sound, upon examination it was noted that it's a pathological fracture in the femur.
An X-ray of the foot of an athletic female with fracture due to stress concentration.
Now we have to describe the fracture, i.e. is it closed or open fracture.
If there is a cut in the skin then the fracture is an open fracture which means that there is a higher incidence of infection which guides us into a completely different treatment of another closed fracture.
Is it simple or comminute, the simple has a better healing than the comminute fracture.
Is it a complete fracture or an incomplete fracture?

Before starting the treatment there are certain things that you need to know about the patient such as his age, handedness (is the patient right or left handed), mechanism of fracture (traumatic pr pathological fracture which may be a result of osteomalacia, bone infection, tumor, osteoporosis, problem in calcium/phosphorus, etc.), when did the fracture happen (e.g. if a patient came with a 4 days old trauma, it will be "most probably" an incomplete fracture but because of the patient ignorance it progressed to complete bone fracture).
Usually patients complain of pain, swelling, deformity or loss of function.
As I said before, the complications doesn't occur due to the trauma/fracture itself but due to trauma to the adjacent structures, (e.g. chest injury, abdominal injury) so we should not focus on the fracture and forget the injury to the adjacent structures.
E.g. in case of mandibular fracture, you should check if there is eye, sinus, brain, cervical spine or airway injury.
THE PRIORITY IS TO SAVE LIFE AND NOT TO TREAT THE FRACTURE.
You should know the history of previous injuries, e.g. if a patient bones gets fractured every 1-2 months, this is an indication that there is something wrong even if the trauma magnitude was significant enough to cause the fracture, further investigations might lead to an underlying pathology at its earliest stages at which we can intervene and fix it, e.g. hyperparathyroidism.
Also, you should know the previous state of the bone, e.g. in a fractured mandible you should know if there was a deformity in the mandible, this is important because it guides you when you treat the fracture.
General medical history is important, whether the patient has hypertension, DM, etc.

Always you have to check the whole body of the patient not just his mandible or maxilla, it's your responsibility to check for other traumatized tissues or you have to refer him to a qualified professional.
Back to the injury site, some of the most important things to examine are the arteries and the nerves.
E.g. the mandibular nerve (sensation) and the vascularity in cases of mandible fracture.
A most common and important investigation to be done in case of fractures is the X-ray.
However, there are certain rules for using the x-rays:
1. Use 2 views; AP and Lateral-medial/medial-lateral, because the bone segments may superimpose each other and hide the fracture.

2. The whole bone should be visible in the x-ray which means that the 2 joints should be seen in the x-ray.
3. Sometimes you should take x-rays of the contralateral bone to compare the 2 bones so that you can detect the fracture; this is an important way to find the fracture in cases of young children.
4. 2 occasions x-rays; sometimes everything indicates that there is a fracture except for the x-ray so you treat the patient as if he has a fracture and re-take an x-ray after 1-2 weeks and most probably it will show the fracture site healing.
The 2 occasions method was used in the past because there were no alternatives, but after the introduction of CT scan, MRI and bone scan, it's now considered an old method.
The bone scan is a way of diagnosing fractures by giving a fluorescent dye to the patient, the dye gets concentrated in the fracture site and then you can know the site of the fracture by taking the appropriate image.
Since MRI is for the soft tissues, we can diagnose the fracture by the presence of the hematoma that is formed due to the fracture.
The dr. is talking about a clinical case at which a female was having a hip pain and the symptoms and examination suggest a fracture but not the x-ray, so a bone scan test was done and there was a significant increase in the uptake of the dye in a specific site in the bone while the contralateral bone showed nothing, to confirm an MRI was done and the incomplete fracture was confirmed.
After taking the history and reaching the definitive diagnosis, we have to treat the patient.
In general, the fractures have 3 principles for treatment which are:
1. Reduction; Reduce the fracture gap
2. Hold and immobilize the fracture
3. Rehabilitate the patient.

-Reduction means to approximate the separated segments of the bone according to its normal anatomy.
It's done in 2 ways according to the configuration and the site of the fracture:
1. Closed: without opening the skin if applicable
2. Open: with opening of the skin under GA
-hold/immobilize the fracture:
There are many ways to immobilize the fracture which include:
1. Cast: used in closed reduction
Advantages: easy to be made without the need of admission to the hospital
Disadvantages: its heavy in weight, it's made by an exothermic reaction which is a source of discomfort for the patient, it might cause stiffness in the joint when used for long duration.
2. Traction: used in cases of femur fracture in an obese patient because it's difficult to do the reduction (you might need to do the reduction by open technique and its success is questionable in this case) so you can use the traction and approximate the bone segments by applying a weight.(this method was developed according to Newton's 3rd law)

Advantages: reduction by closed technique
Disadvantages: the patient needs to be admitted to the hospital, the patient is not allowed to move so there will be a risk for stasis and thrombosis of blood which might lead to pulmonary embolism, back sores might develop due to pressure at the patients back because of prolonged immobilization, sloughing of skin due to the traction plastic elastic cord.
3. Internal fixation: It's done in the operating room after approximation of the 2 segments. E.g. screws, plates and pins.
Advantages: it's a fast procedure of reduction and the patient can be dismissed within 3 days of the fixation, the patient can start using the fractured bone immediately after the fixation.
Disadvantages: risk of infection due to the surgery, fibrosis and scar formation due to the disruption of the muscles which is a very important thing in cases of face surgeries.
The screws, plates and pins are biocompatible so there is no need to remove them after bone healing but some patients insist to remove them after the healing so they can be removed then but the dr. thinks that they should not be removed because by removing them we are endangering the patient by reopening the wound and risking the development of new complications.
4. External fixation: as its name indicates it's fixing the segments externally which is very unpleasant for the patient in an aesthetic point of view, it is used in cases of open fracture in which the segments are exposed because you can't do the reduction and approximation by another way, and you can't leave it as it's because of the high risk of infection and it will be a source of continuous pain, so you have to do the external fixation.
So you have to fix the bone segments only, the other tissues will be managed by the vascular and plastic surgeons by soft tissue grafts or flaps.
External fixation is a rapid procedure at which you drill through the bone and fix the segments together, this is true because you have the bone exposed so there won't be time wasted to expose the bone without damaging the soft tissues, vessels and nerves.
The dr. is talking about a child who has pelvic fracture and a huge hematoma in the abdomen, this child has pelvic, lower limb, head, chest and abdomen injuries.
So the best rapid way to fix the pelvis is by external fixation.

So the only indication for external fixation is open fracture.

The complications of the fracture:
1. Early complications: which happen directly at the time of fracture
2. Late complications: which need time to occur.
It's important to prevent these complications.
Atelectasis: it's defined as the collapse of the alveoli of the lungs, it might happen as a complication of the fracture of the mandible or the maxilla, because after these fractures the patient faces difficulty in breathing which lead to the collapse of the alveoli.
The collapse of the alveoli leads to the accumulation of the secretions inside which is dangerous.
So we have to maintain an open airway for these patients and try to prevent any complication from happening.
Other complications are DVT (deep vein thrombosis), pulmonary embolism (PE), and atrophy of muscles (due to loss/decrease of function).
Late complications:
1. Stiffness of the joint is a late complication of fractured bone, e.g. stiffness of the TMJ due to fractured mandible.

2. Tendon or muscle rupture might occur as a complication, muscles undergo atrophy and shortening after prolonged periods of loss of function.
So the patient should start the rehabilitation sessions immediately after the healing otherwise if he tried to use this bone his muscles and tendons will rupture immediately.



3. Myositis ossificans: the muscle fibers will change to calcified tissue.
To summarize, our responsibility is to prevent the early complications while the physiotherapist are supposed to prevent the occurrence of the late complications.

DONE BY: SARI ADEL MAHASNEH
DATE OF LECT.: 24.April.2012
DR. FADI AL-HADIDI.
Lect. No. 10-Week no.11




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Shadi Jarrar
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تاريخ التسجيل : 2009-08-28
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