Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_958_Библиотеки_им_академика_М_И_Перельмана
.pdf
Fractures Chapter 19: Trauma & orthopaedics 275
https://t.me/med1917
Fracture management principles
Additional management for open fractures:
Always start with A to E / ATLS assessment
1. Analgesia: following WHO analgesic ladder
2. Assess for: document all findings
• Open wounds / skin condition (swab open wounds)
• Nerve damage (motor & sensory function)
• Arterial damage (pulses, CRT, limb/extremity condition)
• Compartment syndrome
3. Order radiographs (at least 2 views & include joint above & below)
4. Provisional reduction if closed fracture
5. Fix/repair:
• Splint/cast (may be sufficient if initial reduction achieves good position)
• External fixation device may be needed as temporary measure before
surgery (allow swelling to reduce)
• Definitive surgery (internal or external fixation)
6. Repeat X-ray after intervention & recheck neurovascular status
Fracture may be a
distracting injury
1. IV ABX (within 1h of injury)
2. Check tetanus status – IV Ig if unvaccinated
3. Irrigation – saline-soaked gauze
4. Splint while awaiting theatre
5. Surgical debridement + fixation
→ Consider taking photos of wound
Simple approach to fracture Mx: 4 Rs
1. Resuscitate
2. Reduce
3. Retain (immobilise)
4. Rehabilitate
FRACTURE FIXATION OPTIONS:
Intermedullary nail Lag screws ± plates External fixation device
If fracture gap
Especially for midshaft
fractures
If fracture gap can be closed
Especially fractures close
to joints
If extensive soft tissue damage
or contamination
Especially high energy injuries
SOFT TISSUE DAMAGE OPTIONS:
1. Leave to heal by secondary intention:
→ Wound edges not opposed, granulation tissue, contraction & scarring
2. Primary closure (e.g. sutures) to allow healing by primary intention:
→ Wound edges opposed, heals with minimal scar tissue
3. Delayed primary closure:
→ e.g. if wound is contaminated → leave 5–10d then close
4. Skin grafts:
→ Blocks of tissue (skin) from another area without integral blood supply
→ Need to be placed in area of good blood supply
5. Skin flaps:
→ Blocks of tissue with integral blood supply (fascia, fat, skin ± muscle)
• local flap: adjacent tissue stretched over defect
• regional/pedicled flap: tissue taken from further away but connected to
original blood supply
• free tissue flap: tissue detached completely & reconnected to blood supply
at site of defect
Topical negative pressure therapy:
Dressing + plastic wrap → pump sucks out air to
provide temporary wound closure / splinting
Benefits: pulls edges together, removes excess
fluid, s contamination
Musculoskeletal disease
276 Chapter 19: Trauma & orthopaedics Fractures
https://t.me/med1917
Pathological fractures
Types
Risk factors for osteoporosis:
• Age/female
• Previous fractures
• Parent fractured hip
• Steroids/smoking
• Hyperthyroidism/hypoparathyroidism
• Alcohol (>3 units/day)
• Thin
• Testosterone low
• Early menopause (<45y)
• Renal/liver failure
• Erosive bone disease (RA/myeloma)
• Diet low Ca / vit D (BAME background)
S
H
A
T
T
E
R
E
D
Total score Fracture risk Recommendation
≥9 33–100% Prophylactic fixation
8 15% Clinical judgement
≤7 <4% Observation ± other
therapy
1. Stress fractures: normal bone*, but repetitive strain
2. Loss of bone: osteoporosis (especially NOF and vertebral fracture)
3. Abnormal bone:
• Osteomalacia (often small, undisplaced fractures)
• Paget’s disease
• Primary tumour (giant cell, myeloma, osteosarcoma)
• Metastases (breast, lungs, thyroid, kidney, prostate)
• Congenital bone disorders e.g. osteogenesis imperfecta
Management
1. Orthopaedic referral + Mirels’ score: determine likelihood that a
pathological lesion will result in fracture
Points scored 1 2 3
Site Upper limb Lower limb Trochanteric
Pain Mild Moderate Functional
X-ray appearance Blastic Mixed Lytic
Size of lesion <1/3 cortex 1/3–2/3 cortex >2/3 cortex
= fracture without significant trauma
*X-ray may only show
periosteal reaction
FRAX score parameters:
• Age, gender, BMI
• Smoking/alcohol
history
• Steroid use
• RA
• Fracture history
DEXA scores:
T-score = SDs below average for young adult
male
Z-score = SDs below average for age-matched
control
Osteoporosis: T-score >2.5 SDs below average
Osteopenia: T-score 1–2.5 SDs below average
Bone profile Ca2+PO
–
4
ALP PTH
Osteoporosis N N N N
Osteomalacia
Paget’s disease N N
1°
N Abnormal
Hyperparathyroid
Bisphosphonates:
• Tablets or injections once a week
• Swallow with water on empty stomach
• Sit upright for 30min after
SE: GI upset, oesophageal ulcers, jaw necrosis
Musculoskeletal disease
BMD
Soft
bones
bone
Soft
bones
2. Search for other mets: CT spine / long bones / pelvis etc.
3. Search for primary: CXR, DRE, thyroid exam / USS, kidney USS
Osteoporosis
→ reduced bone mass & abnormal microarchitecture resulting in skeletal fragility &
increased risk of fracture
→ the result of low peak bone mass &/or bone resorption > formation
PRESENTATION: often asymptomatic until fragility fracture
• Fragility fractures: vertebral crush, NOF, wrist (FOOSH)
• Loss of height / kyphosis / back pain
INVESTIGATIONS:
Must r/o other causes of fragility fractures e.g. malignancy
• History & examination → calculate FRAX score
• Bloods: FBC, ESR, U&Es, TFT, vit D, sex hormones
• Bone profile: Ca2+, PO
–
, ALP*, PTH
4
• Myeloma screen: ESR, electrophoresis, Bence Jones protein
• X-ray – radiolucent bone
• DEXA scan (BMD) = gold standard if mod/high FRAX score
MANAGEMENT10:
Lifestyle: (if osteopenic → repeat DEXA in 2–3y)
• Improve calcium intake
• Exercise (especially weight-bearing)
• Smoking cessation / reduced alcohol consumption
• Medication review: stop or reduce steroids if possible
Physio: reduce falls risk
Medication: (if osteoporotic)
• Vit D supplements – 400–800 U daily
• Calcium supplements – 500–1000mg daily
• Bisphosphonates – alendronic acid 70mg weekly
10
National Osteoporosis Guideline Group (2017) Clinical guideline for the treatment and prevention of
osteoporosis
*ALP = marker
of bone formation
Fractures Chapter 19: Trauma & orthopaedics 277
https://t.me/med1917
Common adult fractures
‘Terrible triad’ elbow fracture
1. Posteriorly dislocated ulna
2. Fractured radial head
3. Fractured coronoid process
± Lateral collateral ligament damage
Management: surgical repair of joint capsule
Colles’ fracture
→ fracture of distal radius with dorsal displacement
Cause: FOOSH (extended wrists)
Epidemiology: especially elderly women (osteoporosis → low impact #)
Associated problems: ulnar styloid #, median nerve damage / carpal tunnel,
EPL tendon injury
Specific initial Mx: check function of median nerve / signs of carpal tunnel
Further management:
1. Undisplaced: dorsal splint then cast for 4–6w
2. Displaced: closed reduction
• Bier’s block anaesthetic + gas & air (haematoma block or sedation are also
an option)
• Traction & reduction to realign fragments
• Placed in cast for 5–6w (check X-rays every 2w)
3. Unstable fracture: surgical fixation (percutaneous wires or plates)
• If fracture re-displaces within cast
• If dorsal radius fracture is comminuted (multi-fragmentary)
• If Smith’s or Barton’s fractures
Smith’s fracture
Elbow dislocation = 2nd most common after
shoulder dislocation → due to FOOSH
Radial head & olecranon fractures
= common due to FOOSH
Avoid cast on elbow:
Instead use sling, or surgery with tension
band wires or plates
(joint stiffens too much in plaster)
Fig. 19.17 Colles’ fracture.
Features of Colles’ fracture:
1. Dorsal translation & angulation
2. Flattened radial inclination
3. Radial impaction & shortening
Appearance known as ‘dinner-fork’ deformity
→ fracture of distal radius with volar displacement
Cause: FOOSH (flexed wrists)
Management: initial Mx as for Colles’ PLUS surgical fixation
Scaphoid fracture
→ proximal (15%), middle (80%) or distal (5%)
Cause: FOOSH / direct impact to hand
Epidemiology: all ages
Symptoms: pain & swelling in anatomical snuffbox, weakness of pinch grip
Associated problems: radial #, avascular necrosis (especially of proximal #)
Investigations: scaphoid series (PA, lateral + oblique + ulnar deviation)
Management: refer to orthopaedics as high risk of AVN
1. Undisplaced: cast including thumb for 8–12w
2. Displaced: internal fixation with a screw → risk of non-union = 5–10%
Musculoskeletal disease
278 Chapter 19: Trauma & orthopaedics Fractures
(a)
https://t.me/med1917
Forearm fractures
→ ulna and radius form a ‘ring’ (normally breaks in 2 places)
Bankart lesion: damage to the labrum (usually
anterior inferior part). If lesion affects the bone it
is known as a ‘bony Bankart’ lesion.
Hill–Sachs lesion: dent in humeral head
caused by impaction against the glenoid rim
during dislocation.
Fig. 19.20 Hill–Sachs +
Bankart lesions.
GALEAZZI FRACTURE:
Fracture of distal radius +
dislocation of distal radioulnar
joint (wrist)
Fracture
Dislocation
Fig. 19.18 Forearm fractures: (a) Galeazzi; (b) Monteggia.
MONTEGGIA FRACTURE:
Fracture of proximal ulna +
dislocation of proximal radioulnar
joint (elbow)
Management:
Open reduction & internal fixation
Glenohumeral dislocation
ANTERIOR DISLOCATION (96%)
Cause: fall on extended arm
Epidemiology: most common dislocation
Signs:
• Swelling & deformity (squaring of shoulder)
• Gap under acromion
Complications:
• Axillary nerve damage (shoulder flexion &
abduction)
• Brachial plexus palsy
• Rotator cuff tears
• Recurrent dislocation (Bankart lesion /
labrumdamage)
Investigations: X-ray & MRI (assess rotator cuff
tears)
Management:
Closed reduction under sedation
(e.g. Hippocratic method)
+ check with X-ray & immobilisation for
1w in cuff & collar sling
Dislocation
Fracture
(b)
Humerus
Fig. 19.19 Anterior shoulder
dislocation.
Musculoskeletal disease
POSTERIOR DISLOCATION (RARE):
Cause: may follow epileptic fit / seizure
or polytrauma
Signs: ‘light bulb sign’ on X-ray
Complications:
• Locking → reduced ROM (esp.
external rotation)
• Hill–Sachs lesion causing
instability
Fig. 19.21 Light bulb sign in posterior
shoulderdislocation.
Fractures Chapter 19: Trauma & orthopaedics 279
https://t.me/med1917
Acromioclavicular dislocation
Cause: fall directly on to shoulder, contact sports, RTA
Management: depends on Rockwood grading
Type 1 or 2: sling for 1–2w then physio
Type 3 or 4: surgical fixation with a plate (type 3 can sometimes be managed
non-operatively)
Clavicular fracture
→ common fracture in all ages (5% all fractures)
Cause: direct trauma or fall on shoulder
Symptoms: tenderness, visible deformity, tenting of skin
Describing the fracture: distal section displaced distally & inferiorly
Complications:
• Brachial plexus injury, vascular damage, skin necrosis
• Rib fracture & pneumothorax
• Non-union (1–5% risk → more likely if medial/lateral #)
Management:
1. Conservative: → collar & cuff sling for 4–6w + analgesia & rest
2. Surgery: → plate & screws or pin
Classifying AC dislocation: Rockwood grading
Type 1: no joint disruption – AC ligament sprain
Type 2: <50% vertical displacement – CC
ligament sprain
Type 3: 100% vertical displacement – AC & CC
ligaments torn
Type 4: posterior displacement – AC & CC
ligaments torn
Indications for surgery in clavicle #:
• Open fracture
• Neurovascular damage
• High risk non-union
Humeral shaft fracture
→ proximal (30%), middle (60%), distal (10%)
Cause: direct or indirect trauma (high energy or if elderly with weak bones)
Type: usually spiral or oblique
Complications: radial nerve injury
Management:
1. Immobilised with cast ‘U-slab’
2. Replace with brace after 2–4w
Surgical management: plate/screws or rarely external fixation
Proximal humerus fracture
→ most common fracture of humerus
→ described based on number of fragments
Cause: falls → elderly women (weak bones) or high energy falls (cyclists etc.)
Complications: axillary nerve damage, brachial plexus palsy
Management:
1. Collar & cuff sling immobilisation + analgesia
2. If younger / high demand: screws/plate → risk avascular necrosis
Indications for surgery in humeral shaft #:
• Open fracture
• Neurovascular damage
• Multiple trauma
• Displaced transverse fracture
Musculoskeletal disease
280 Chapter 19: Trauma & orthopaedics Fractures
https://t.me/med1917
Neck of femur (NOF) fracture
Risk factors for NOF #:
• Osteoporosis
• Those at risk of falls
Mortality of NOF #:
10% at 1m
33% at 1y
Complications of NOF #:
• Avascular necrosis (AVN) of femoral head
• Non-union (5–30%)
• Dislocation (10%)
→ very common in elderly population (especially females & those in institutional
care)
Cause: in the elderly following a fall
→ Important to assess for comorbidities / complications of fall e.g. AKI
→ Important to assess baseline mobility (determines Tx options)
Classification: intra- or extra-capsular
1. Intracapsular fractures: the Garden classification → based on plain AP
radiograph
Fig. 19.22 The Garden classification.
Risk factors for AVN:
• Irradiation
• Leukaemia & lymphoma
• Sickle cell disease
• Alcoholism
• Steroids
• HIV, CMV, hepatitis, rubella
Only consider total hip replacement if
patients:
1. Were able to walk independently outdoors
with no more than one stick
2. Are not cognitively impaired
3. Are medically fit for anaesthesia & the
procedure
(hemiarthroplasty = alternative)
1. Incomplete or
valgus impacted
2. Complete but
not displaced
3. Complete and
slightly displaced
4. Complete and
fully displaced
Identify on radiograph by looking at alignment of trabecular lines.
(1 & 2 = difficult to spot)
Specific management11:
• Garden 1 & 2: blood supply
intact → cannulated screws
or 2-hole dynamic hip screws
• Garden 3 & 4: blood supply
compromised → total or
hemiarthroplasty (if fit
& young fix not replace
(with screws)
General management:
• VTE prophylaxis
Complete & fully
displaced
intracapsular
fracture
Fig. 19.23 Type 4 Garden classification.
“1 & 2, fix with screws”
“3 & 4, will need more”
• Analgesia – FNB or FICB
• Physio/rehab – weight-bearing recommended
2. Extracapsular fractures: → intertrochanteric or subtrochanteric
Management:
• Intertrochanteric: blood supply intact
→ 4-hole dynamic screws (or IM nail)
• Subtrochanteric: blood supply intact
→ intramedullary nail (DHS = too weak)
Musculoskeletal disease
Cause of subtrochanteric fracture:
→ High impact trauma
→ 2° to lytic lesions (need CT)
11
AAOS (2021) Management of hip fractures in older adults
Fig. 19.24 Subtrochanteric fracture.
Fractures Chapter 19: Trauma & orthopaedics 281
C
B
A
https://t.me/med1917
Patellar fracture
*occurs when knees hit dashboard in RTAs
Cause: ‘dashboard’ injury*, fall directly onto knee, direct blow, sudden quad
contraction
Associated problems: tendon/ligament damage, avascular necrosis
Management: knee brace or surgical fixation (with tension band wires)
Tibial plateau fracture
→ most commonly lateral plateau
Cause: high energy trauma or elderly with weak bones
Symptoms/signs: pain, swelling & valgus/varus deformity
Investigations: X-ray + MRI → fat-fluid level on lateral X-ray
Associated problems: compartment syndrome & big soft tissue injury
Management:
1. Undisplaced: cast or knee brace for 6w
2. Displaced: internal fixation with screws/plates
Tibial shaft fracture
→ usually spiral fracture (caused by twisting force)
Epidemiology: most common long bone fracture in adults (especially young ♂)
Associated problems: vascular injury, compartment syndrome & big soft tissue
injury
Management:
1. Undisplaced: closed reduction + cast for 16w (or functional bracing)
• Initially whole leg cast, then below knee cast after 4w
2. Displaced/open: interlocking intermedullary nailing
• May need to start with external fixator device while swelling reduces
Calcaneal fracture
→ most common tarsal fractured
Cause: fall from height, RTA
Associated problems: soft tissue injury, skin necrosis / blisters
Signs: shortened, widened heel with varus deformity + reduced Bohler’s angle
Investigations: calcaneal series: lateral and axial (from below) views
Management: cast or internal fixation
Arteries at risk in tibial shaft #: peroneal,
anterior & posterior tibial (check pulses, CRT,
temperature)
Weber classification (lateral malleolus / fibular
fractures):
A: below ankle joint, with intact syndesmosis
(stable)
B: at level of ankle joint (stable or unstable:
check talar shift)
C: above ankle joint + medial malleolus fracture
(unstable)
Ankle fracture
→ classified with Weber classification according to relation to joint
Cause: twisting motion
→ Skiers, footballers / high heels
→ Osteoporotic women
Associated problems: ligament
disruption
Signs: tenderness, extensive swelling
& bruising, inability to weight-bear
Investigations: X-ray – AP, lateral
& mortise views
Complications: ankle osteoarthritis
12
BOAST (2016) The management of ankle fractures.
Management12: may need external
fixation first if swelling too extensive for
cast/incision
↳ Weber A: usually stable
→ Cast/splinting for 5–6w
↳ Weber B & C: variable stability
(often malleolar fracture & ligament
disruption)
→ Closed reduction & refer for ortho
review for possible internal lag
screw fixation (with plates)
Fig. 19.25 Weber classification.
Musculoskeletal disease
282 Chapter 19: Trauma & orthopaedics Fractures
https://t.me/med1917
Maisonneuve fracture
Unstable ankle injury =
deltoid ligament injury ± medial malleolar
fracture
→ X-ray shows widened syndesmosis +
talar shift
→ fracture of proximal fibula + unstable ankle injury (talar shift)
If notice talar shift on ankle X-ray, but no fracture, need to check higher up leg for
proximal fibula fracture
Pilon/plafond fracture
→ distal tibial fracture due to talus being forced upwards into tibia
Cause: fall from a height
Complications:
• Fractures to knee
• Vertical shear fracture of pelvis
• Vertebral fractures
• Vascular damage: anterior & posterior tibial, peroneal
• Nerve damage: superficial peroneal nerve
Management: ATLS approach
→ Temporary external fixation then internal fixation → poor prognosis (high risk OA)
Wedge fracture of the spine
→ a fragility fracture seen in the elderly
Cause: fall from standing height in elderly (osteoporotic bones)
Presentation:
• Acute onset lower back pain (worse with movement)
• Localised tenderness
→ Multiple wedge fractures cause hyperkyphotic deformity
Investigation:
• X-ray
• CT – if unsure of stability
• MRI – if neurological signs
Management:
• Analgesia & early mobilisation
• Kyphoplasty: inject cement to stabilise
• Long-term osteoporosis management
Musculoskeletal disease
Traumatic fracture of C-spine
Cause:
→ Young: RTAs or extreme sports
→ Elderly: fall from standing
Investigation:
• Full neurological assessment
• X-ray (AP, open mouth, lateral ± swimmer’s)
• CT – first line in trauma patients
• MRI – if neurological signs
Management: ATLS approach
• Triple immobilisation – hard collar, board & blocks
• Strong analgesia
• Spinal surgery referral to realign/stabilise fracture
Fractures Chapter 19: Trauma & orthopaedics 283
Buckle fracture
Ulna
Radius
U
https://t.me/med1917
Common paediatric fractures
Incomplete fractures
→ Common in children due to softer / more flexible bones
→ Bones bend/compress rather than break
GREENSTICK FRACTURES = partial break in one
side causes other side to bend
→ Common mid-shaft of forearm and lower leg
BUCKLE/TORUS FRACTURES = compression
on one side of the bone causing bulging cortex
→ Commonly involve distal metaphysis of radius
→ Following FOOSH
→ Appears as ‘base of pillar’ / bulge & often no
uckle fracture
Radius
fracture line seen
HAIRLINE STRESS FRACTURES = small ‘cracks’ that do not
traverse entire bone
→ Usually from overuse / repetitive stress-bearing motions
e.g. track runners, gymnasts, dancers
Fig. 19.26
Most common fracture sites in kids:
• Distal radius (FOOSH) & hand
• Clavicle
• Tibial shaft, ankle & foot
• Radial shaft & elbow
Complete fractures
COMMINUTED/MULTIFRAGMENTARY FRACTURE = bone broken into
>2 pieces / crushed into fragments
BUCKETHANDLE FRACTURE = fragmentation of corner of metaphysis
→ Indicates non-accidental injury
Growth plate fractures
→ Unique to children (common in growth spurt when physes are weakest)
→ Typically caused by great force during sports or playground accidents
→ Classified with Salter–Harris system13 → determines Tx options
Salter–Harris type Treatment
I (S)
II* (A)
III (L)
IV (T)
V* (ER) Surgery
* Most common * Likely to affect bone growth
Splinting or casting
Open reduction & internal fixation
S
Straight
across
A
AboveLLower or
BeLow
Fig. 19.28 Salter–Harris classification.
T
Two or
Through
Fig. 19.27 Red arrow shows ‘bucket-handle’
fracture suggestive of NAI.
E R
Erasure of
growth
plate
or cRush
Management options for fractures
1. Simple cast/splint
2. Brace/boot
3. Surgical fixation with metal pins/screws + analgesia
13
Salter R, Harris WR (1963) Injuries involving the epiphyseal plate. J Bone Joint Surg Am, 45:587
Musculoskeletal disease
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана