Bones and Fractures 1 (CMPP)

What is the approach to assess MSK injurt

Do the ABCs

Control hemorrhage

Splint damaged limbs

Repeat assessements of NV status

How will fractures appear on physical exam

Swelling,

Ecchymosis,

Deformity

Point tenderness

Pain with stress of bone

What neuro exam should be done for fractures

Sensation

Reflexes

Consider motor strength

What vascular exam should be done for fractures

Pulses

Cap Refills

Color

Warmth

What should be included for XRs for fractures

The joint above and bloew

2 different plane views at 90 degrees

What can help assess if a bone is fractured or not on XR

Comparsion view

What fractures are common in fall from height injury

Calcaneus

Tibial Plateau

Hip

Vertebral Body

Fractures

loss of integrity of bone, usually due to mechanical trauma

What is required for successful bone healing

Intact/adequate blood supply

Immobilization

Absence of infection

What are the stages of fracture healing

Hematoma Formation

Soft Callus Formation

Bony Callus Formation

Bone Remodeling

How long does the Hematoma Formation stage of bone healing take

0-48 hours

How long does the Soft Callus Formation stage of bone healing take

0-2 weeks

How long does the Bony Callus Formation stage of bone healing take

2-12 weeks

How long does the Bone Remodeling stage of bone healing take

3+ months, up to years

Hematoma Formation Stage

First stage of fracture healing where a hematoma forms due to distrupted blood vessls

What occurs in the soft callus formation stage

Platelets & WBCs release growth factors to stimulate proliferation of osteoblasts & chondroblasts

Osteoblasts will lay down osteoid (woven tissue)

Chondroblasts will lay down early cartilage tissue

How do soft callus appear on XR

Fluffy / Cloud Like around a fracture

Fracture line widens

What occurs during bony callus formation

Involves calcium, phosphate to create hardened bone callus

Mineralization of new tissue

As cartilaginous callous calcifies, it becomes radio-opaque

What are factors that leads to larger bony callus formations

Diaphyseal fractures

larger bones

Motion during healing

Infection

What are factors that leads to smaller bony callus formations

Smaller bones

Metaphyseal fractures

Impaction injury

ORIF

What determines the bone remodeling process

Weight bearing/stress stimulates bone remodeling process

• Osteoclasts will remove tissue NOT under stress

• Osteoblasts will reinforce tissue that IS under stress

Osteoclasts

Cells that break down bone

Osteoblast

Cells that make bone

Wolff’s Law

bones will adapt to the degree of mechanical loading, such that an increase in loading will cause the architecture of the internal, spongy bone to strengthen, followed by the strengthening of the cortical layer

What factors determine the time it take for remodeling to occur

Bone involved & degree of soft tissue trauma

Patient age & comorbidities

Vascular supply

What substances intefere with bone remodeling

Smoking

Sterodis

Physeal (growth plate) fractures

Disruption in the cartilaginous physis of bone with or without the involvement of epiphysis or metaphysis

How are Physeal fractures classified

Salter-Harris Fracture

Types of Salter harris fracutres

Type I – Epiphyseal plate alone

Type II – Epiphyseal plate and metaphysis

Type III – Epiphyseal plate and epiphysis

Type IV – Epiphyseal plate, metaphysis and epiphysis

Type V – crush fracture of epiphyseal plate

What is the prognosis for Salter-Harris Fractures

Type I’s and II’s do well

Type III and IV may limit joint motion

Type IV’s and V’s can develop early fusion of epiphysis and shortening of that bone

Most Common Salter Harris Fracture

Type 2

Corner Sign

A fracture where part of the bone remains attached to the growth plate while the rest is displaced

Sign of SH-2 Fractures

Spiral / Torsion Fracture

Fracure Results from twisting or rotational force

Greenstick Fracture

Partial thickness fracture where only the cortex and periosteum are interrupted on only one side of the bone

What can increase risk for Greenstick fracture

Malnurtrition / Vitamin D deficiency

Comminuted Fracture

Fracture resulting in 3+ pieces of bone fragment

Open Fractures

Any fracture that communicates with the outside is considered open

Open Fractures have high risk for

Infections

Open Fractures often need what during treatment

Surgical debridement

What is closely related to the infection risk of open fracture

Time from injury to first Abx dose

What are common pathogens for open fracture infections

S. aureus

S. epidermidis

Aerobic GNR

What pathogens are common in open fractures with water exposire

Pseudomonas

Aeromonas

Vibrio spp.

Type 1 Open Fracuture

Wound < 1 cm

Minimal contamination

Communication and Soft Tissue Damage

Type 2 Open Fracture

Wound > 1 cm

Moderate soft tissue damage

Minimal periosteal stripping

Type 3 Open Fracture

Severe soft-tissue and substantial contamination

Covered adequate

Type 4 Open Fracture

Severe soft-tissue and substantial contamination

Covered poorly

Type 5 Open Fracture

Arterial injjury

Abx For Type 1/2 Open Fracture with no Soil or Water Contaminant

Cefazolin IV q8h

• PCN Allergy → vancomycin

Abx For Type 1/2 Open Fracture with Soil Contaminant

Cefazolin IV q8h + Metronidazole IV q8h

PCN Allergy → clindamycin

Abx For Type 1/2 Open Fracture with Water Contaminant

Cefazolin IV q8h

PCN Allergy → vancomycin

Abx For Type 3 Open Fracture with no Soil or Water Contaminant

Ceftriaxone 2g daily

PCN Allergy → Clindamycin 900mg IV q8h

Abx For Type 3 Open Fracture with Soil Contaminant

Ceftriaxone 2g IV daily + Metronidazole 500 IV q8h

PCN Allergy → Clindamycin 900mg IV q8h + Levofloxacin 750 mg IV daily

Abx For Type 3 Open Fracture with Fresh Water Contaminant

Piperacillin-tazobactam (zosyn) 4.5g IV q6h

PCN Allergy → Imipenum 500mg IV q6h or Meropenem 1g IV q8h

Abx For Type 3 Open Fracture with Sea Water Contaminant

Levofloxacin 750 mg IV daily + Metronidazole 500mg IV q8h

Who should be consulted for treatment of fractures

Vascular

Ortho

Neuro

What is the general rule of how to splint fracture

as it presents

joint above and below if possible

Benefits to Splints

Noncircumferential

Allows for better inspection of injury site

Accommodates swelling

Less pressure-related complications

Static Splint

No moving components

Dynamic Splint

Uses articulations and force components to constantly put a pull on the tight or healing tissue

What should be done prior to applying a splint

Assess for open fracture

Check (and re-check) neurovascular status

Remove jewelry

Clean skin, moisturize, separate fingers and toes with cotton

Immobilize extremity in position of function

What should be done after applying a splint

Re-check and document neurovascular status

Assess for and document absence of signs of compartment syndrome

Check for sharp edges or areas of irritation

Referral to orthopedic clinic for casting

What patient education should be given to splints

Elevate to decrease pain and swelling

Refrain from sticking things under cast to scratch

Keep cast clean and dry unless specifically made waterproof

Follow-up 1 week after cast/splint applied

Use analgesics as directed

Call or go to ER for extreme pain or tightness

How do we relieve itching / dry for casts

Hair dryer on cooil

Complications from Casting / Splinting

Compartment syndrome

Joint stiffness

Loss of reduction/deformity

Neurovascular compromise

Pressure injuries

Skin necrosis

What are the closed options for fracture treatment

Reduction

Traction

Casting/Bracing

External Fixation

What are the open options for fracture treatment

Open reduction, casting

Pin fixation

Plates and screws

Intramedullary fixation

Specialized instruments

Complications from Fractures

Neurovascular injury

DVT

Infection

Non-union/Malunion

Joint stiffness