fracture and dislocation

fracture

partial or complete interruption in the continuity of bone

open fx

the bone is exposed due to severe soft tissue injury, are associated with a significant risk of infection and poor wound healing

fx complications

• acute nerve and vascular injury

• compartment syndrome

• avascular necrosis

• non-union repair

types of fractures

• hairline

• oblique displaced

• oblique nondisplaced

• linear

• comminuted

• spiral

• segmental

closed simple

The bone is broken, but the skin remains intact

open (compound)

The broken bone penetrates the skin, or a wound exposes the fracture site

transverse

The fracture line runs straight across the bone

oblique

The fracture line occurs at an angle across the bone

spiral

A twisting force causes a fracture that wraps around the bone

comminuted

The bone breaks into three or more fragments

greenstick

An incomplete fracture in which one side of the bone breaks and the other side bends; common in children

buckle (torus)

Compression causes the bone to bulge outward without completely breaking; common in children

impacted

One fragment of bone is driven into another fragment

compression

The bone collapses under pressure, often seen in vertebrae

avulsion

A tendon or ligament pulls a piece of bone away from the main bone

stress

Small cracks that develop from repetitive loading or overuse

depressed

A portion of bone is pushed inward, commonly seen in skull fractures

fracture classified

• anatomy

• extent

• orientation

• displacement

fx anatomy

Location: affected bone (proximal, distal)

Position: diaphysis , metaphysis, epiphysis

extent of fx

Complete

Incomplete

orientation of fx

transverse, oblique, spiral

displacement of fx

Rotated: rotation around the longitudinal axis

Angulated: angulation of the axis

Translated: lateral movement of the bone fragments

Longitudinal displacement of bone fragments

Distraction: elongation

Impaction: shortening

fragmentation

Comminuted fracture: more than two fracture lines resulting in multiple bone fragments

Segmental fracture: two fracture lines with a bone fragment between the proximal and distal portions of the bone

salter- harris fx

• growth plate

• I: S - straight across

• II: A - above

• III: L - lower or below

• IV: T - two or through

• V: ER - erasure of growth plate or crush

pathologic fx

A spontaneous fracture following mild physical exertion or minor trauma; (e.g., lifting something, bending over, or sneezing/coughing) due to abnormal weakness of the bone that is caused by an underlying condition such as:

• Osteoporosis (most common cause)

  Paget disease of bone

  Osteopetrosis (abnormal, dense bone)

  Osteomalacia (bone softening)

  Osteogenesis imperfecta

stress fx

Complete bone fracture caused by repetitive stress without underlying bone pathology or disease affecting the bone

colles fx

distal radius ± distal ulna

smith fx

distal radius

monteggia fx

proximal one-third of the ulna and dislocation of the radial head

galeazzi fx

distal radial shaft and dislocation of the distal radioulnar joint

boxer’s fx

A fracture of the 4th or 5th metacarpal neck, usually caused by a closed fist forcibly coming into contact with a solid surface

• Often results from punching at a solid object, resulting in the 5th MC making the first point of contact

avulsion fx

Common in the foot when landing on an inverted ankle

• Muscles of the leg try to pull the ankle into neutral position, but the weight of the body coming down prevents any motion

jones fx

• a transverse fracture at the base of the fifth metatarsal

• Commonly results from sudden inversion of the foot with the ankle plantarflexed or from repetitive stress

jones fx s/s

pain

swelling

tenderness

difficulty bearing weight along the outside of the foot - particularly over the proximal fifth metatarsal

• Poor blood supply to the 5th metatarsal, so proper healing is imperative

jones fx treatment

• Treatment depends on the patient and fracture characteristics and may include non-weight-bearing immobilization in a cast or boot

• competitive athletes and displaced fractures often require surgical fixation with an intramedullary screw to promote faster healing and return to activity

clinical features of fx

Pain, redness, and swelling at the site of injury

Deformity and axis deviation

Bone fragments penetrating the skin

Palpable step-off or gap

Bone crepitus

Concomitant soft tissue injuries

Neurovascular compromise below the site of injury

Fracture Characteristics That Increase Severity

• Open fracture

• Comminuted fracture

• Fractures involving a joint surface

• Fractures with significant displacement

• Fractures associated with nerve or vascular injury

grade I open fx

• wound < 1cm

• clean wound with no contamination

grade II open fx

• wound size > 1cm but no less than 10 cm

• no extensive avulsions or extensive soft tissue damage

grade IIa open fx

• caused by high energy events

• damage to soft tissue but bone is still covered by tissues

grade IIIb open fx

• extensive soft tissue damage

• damage to the bone and periosteum

• chances for severe contamination

• surgical procedures to cover exposed areas with soft tissue using free or rotational flaps

grade III C open fx

associated vascular injury

fx care

•Assess – Check circulation – Splint – Recheck circulation – Refer

splinting 101

Splint the injury in the position found unless circulation is compromised or protocol directs otherwise

Immobilize the joints above and below the suspected fracture

Pad all splints appropriately

Secure the splint without compromising circulation

proper open fx management

Cover the wound with a sterile dressing

Control bleeding with direct pressure around the wound when possible

Do not push exposed bone back into the wound

Treat as a medical emergency and activate EMS when indicated

monitor for shock

Pale, cool, clammy skin

Rapid pulse

Altered mental status

Decreasing blood pressure

common fx care mistakes

Do not:

Attempt to reduce (realign) most fractures unless specifically trained and authorized by protocol

Test range of motion when a fracture is suspected

Allow an athlete to return to participation when a fracture is suspected

Remove a properly fitting splint unnecessarily

Ignore changes in circulation, sensation, or motor function

compartment syndrome 6 ps

pain

pallor

pulselessness

paresthesia

paralysis

poikilothermia (loss of thermal homeostasis)

Radiographic signs of a fracture

radiolucent fracture line

cortical disruption

general approach to fx treatment

General approach

• Wound care

• Pain management (e.g., non-opioid analgesics, opioids)

• Fracture care (conservative)

  • Immobilization (splint)

  • Minimize activity (e.g. weight bearing)

• Fracture care (surgical)

  • Anatomic reduction

  • Fixation

  • Immobilization

acute fx complications

• Neurologic and vascular injury (e.g., bleeding, hematoma, seroma)

• Compartment syndrome

• Wound infection, osteomyelitis

long term fx complications

Avascular necrosis

Post-traumatic osteoarthritis

Complex regional pain syndrome

Joint stiffness/contracture

Joint instability

Heterotopic (soft-tissue) ossification

Children: growth disturbances after growth plate injury (Salter-Harris fracture)

fx complications

• Complications can arise due to immobilization

  • Muscle atrophy and joint stiffness are common

  • Thrombosis, pulmonary embolism are serious

  • Infections (e.g., pneumonia, urinary tract infection)

joint dislocation

• ATs must comply with their state practice regulations and take into account the predetermined protocols of their supervising physician and institution and their own training and experience in reducing the specific joint dislocation

• If permitted, written standing orders should be provided by the supervising physician specifically indicating the circumstances under which the AT should attempt to reduce a dislocated joint, which joint dislocations the AT may attempt to reduce, and the reduction technique(s) to be used

variables to determine whether or not to reduce a dislocated joint

• The amount of time the joint has been dislocated

  • the longer a joint has been disarticulated, the more urgent or difficult the subsequent onsite reduction may be

• The ease of the joint reduction

• The patient’s age and general health

• The presence of any concomitant injury (including fracture)

• Any neurovascular compromise

• Whether the injury represents a recurrent dislocation

When a joint is dislocated, the main treatment priorities are…

1) avoid neurovascular complications

(2) reduce the joint as atraumatically as possible

Benefits of Joint Reduction

Avoidance of muscle spasm and swelling, which can severely limit delayed attempts at reduction

Reduction of pain and discomfort experienced by patients requiring transport and treatment at medical facilities

Restoration of vascular flow to the limb, less articular cartilage injury, and decreased skin compromise

Eliminate need for immediate patient transfer to a medical center for evaluation and treatment

joint reduction considerations

A history should be obtained

A comprehensive musculoskeletal assessment, including a neurovascular examination, must be completed before the decision is made to reduce a dislocated joint

Reduction of a joint dislocation should not be undertaken if the patient presents with any signs or symptoms consistent with a fracture of 1 or more bones of the involved articulation

A neurovascular examination, including sensory, motor, and vascular status, should be repeated after each reduction attempt

All joints that are reduced onsite should be immobilized

The patient should be treated for pain and spasm and referred for further treatment, including radiographs to assure proper bony alignment and identify any associated fractures

If the patient is young enough that the epiphyseal plates may still be open (as late as 22 years of age), onsite reduction of a joint dislocation should not be attempted because a fracture is highly likely

finger dislocation reduction

traction

exaggeration