Fractures & Dislocations

ALMAS KHAN Radiology Technologist

KHORFAKKHAN HOSPITAL

TALK PLAN

Signs or Symptoms of a Fracture Types of fracture and dislocations Emergency care for fracture patient Diagnosis of fracture Treatment of fracture Physiology of fracture healing Role of Radiographer

FRACTURE

i. Bones form the skeletal frame work of the body and supports the body against gravity.

ii. It helps in movement and activities. iii. Bones protect some body parts.iv. Bone marrow produces blood products.

v. When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces

vi. A bone fracture (sometimes abbreviated FRX or Fx or Fx or #

Description of Location of #• Which bone?• Thirds (long bones)

• Proximal, middle, distal third

• Anatomic orientation• E.g. proximal, distal, medial,

lateral, anterior, posterior

• Anatomic landmarks • E.g. head, neck, body / shaft,

base, condyle

• Segment (long bones)• Epiphysis, physis, metaphysis,

diaphysis

Epiphysis

Metaphysis

Diaphysis

(Shaft)

Physis

Articular Surface

Signs or Symptoms of a Fracture

• Pain and tenderness• Loss of function• A wound (with bone sticking out)

• Deformity• Unnatural movement• Shock• Swelling and bruising

Emergency Care For Fractures& Dislocations

• Administer O2• Control any bleeding & dress open wounds• Check distal pulse• Apply slight traction—if splinting long bones in arms and

legs If injury to a joint• DO NOT apply traction• Splint in the position found• Apply splint above & below the fracture• Re-check distal pulses after splinting• Control swelling with ice pack & elevation if distal pulse is

present and strong• Maintain body temperature

Diagnosing Bone Fractures

• X-rays of injured area• Some fractures are

difficult to see in an x-ray, so a CT scan, MRI, or other bone scans are used

COMPLETE

• bone is completely broken into 2 or more fragments.

• -eg:• transverse fracture • oblique fracture• spiral fracture• impacted fracture• comminuted fracture• segmental fracture

INCOMPLETE

• bone is incompletely divided and the periosteum remains in continuity.

• -eg:• greenstick fracture • torus fracture• stress fracture• compression

fracture.

Types of Fractures

COMPLETE FRACTURES

INCOMPLETE FRACTURE

Open Fractures

An open fracture is a broken bone that penetrates the skin. This is an important distinction because when a broken bone penetrates the skin there is a need for immediate treatment, and an operation is often required to clean the area of the fracture.

The risk of infection, there are more often problems associated with healing when a fracture is open to the skin.

Comminuted fracture

• Comminuted fracture - a fracture in which the bone breaks into more than two fragments; usually caused by severe forces

Spiral Fracture

• Fracture where at least one part of the bone has been twisted

Spiral fracture of femur

Oblique Fracture

• When the bone is broken on a steep angle

fibula

Transverse Fracture

• A fracture that occurs at a right angle to the bone’s axis

Impacted Fracture

• A fracture in which the ends of bones are driven into one another (common in children)

• Also known as a “buckle fracture”

Greenstick

• An incomplete fracture in a long bone of a child (bones are not yet fully calcified and they break like a green stick)

Compression Fractures

• Compression Fracture usually occurs in the vertebrae.

• When the front portion of vertebrae in the spine collapses due to Osteoporosis which causes bones to become brittle and susceptible to fracture , with or without trauma.

• An x-ray of the spine can reveal the bone injury , however sometimes a CT scan or MRI will be used to insure that no damage is done to the spinal cord.

Hairline Fracture• A very thin crack or break in the bone

Hairline fracture of the foot

Stress Fracture• Stress fracture - fracture without being

visibly broken; microscopic fissures in bone that forms without any evidence of injury to other tissues; caused by repeated strenuous activity (ex: running)

Skull Fracture and Sutures

Depression FractureA depressed skull fracture is a break in a cranial bone (or "crushed" portion of skull) with depression of the bone in toward the brain.

The brain can be affected directly by damage to the nervous system tissue and bleeding.

The brain can also be affected indirectly by blood clots that form under the skull and then compress the underlying brain tissue (subdural or epidural hematoma).

Pathologic Fracture• A type of fracture that is a

secondary result of another illness or chronic condition that weakens the bones of the skeletal system

• The x-ray to the right shows thinning of the femurs, resulting in a fracture of the proximal end of the right bone

• x-ray showing pathological fracture right humorous due to bone cyst

Pediatric Supra-condylar fracture

Supracondylar fractures of the elbow are one of the most common fractures in children

Radiographer with a significant challenge. In addition to the normal difficulties associated with imaging children, the radiographer must consider that the patient may be in severe pain

Scaphoid Fracture History

FOOSH Dull, deep, ache in radial side

of wrist occur most commonly from a

fall on the outstretched hand early (first week) may appear

negative An X-ray a couple of weeks

later may then more clearly reveal the fracture. In questionable cases, MRI scan, CT scan, or bone scan

Colle`s and smith`s fracture

• Fig : -

Describe by : - Abraham colle`s - 1814. It is not just fracture lower end of radius but a fracture dislocation of the inferior radioulnar joint .

Occurs about 2.5 cm above the carpal extremity of the radius .

A Smith's fracture, also sometimes known as a reverse Colles' fracture is a fracture of the distal radius. It is caused by a direct blow to the dorsal forearm or falling onto flexed wrists, as opposed to a Colles' fracture which occurs as a result of falling onto wrists in extension.

Colle’s fracture Smith’s fracture

• Fig : -

BENNETT’S FRACTURE

• Intra-articular fracture/dislocation of base of 1st metacarpal

• Small palmar fragment continues to articulate with trapezium

• Mechanism: forced abduction of thumb

• Treatment: open reduction and internal fixation

Salter – Harris

I – S = Slipped . Slipped growth plate

II – A = Above . The fracture lies above the growth plate (metaphyseal)

III – L = Lower . The fracture is lower than (below) the growth plate ( epiphyseal)

IV – T = Through. The fracture through the growth plate including the ( metaphysis and epiphysis )

V – R = Rammed . The growth plate has been rammed or ruined ( the physis suffers a compression injury )

Associated Complications: Visceral injury

• Fractures around the trunk are often complicated by visceral injury.– E.g. Rib fractures pneumothorax /

spleen trauma / liver injuries.– E.g. Pelvic injuries bladder or

urethral rupture / severe hematoma in the retro-peritoneum .

• Rx: Surgery of visceral injuries

HOW FRACTURES HEAL?-Physiology

When bone breaks, so do the blood vessels that supply the bone

1) a clot forms in the damaged area2) blood vessels and cells invade the clot and

produce a fibrous network and cartilage between broken bones (callus)

3) osteoblasts enter callus and begin forming cancellous bone

4) Cancellous bone is remodeled to form compact and cancellous bone; repair is complete

• Healing by callus• Healing without callus

Treatment of Fractures

• There are two main types of treatments:– External fixation - casts– Internal fixation - surgery

• Wires - used on small fractures

• Plates - hold two lengths of bone together with screws

• Nails or rods - placed in centers of long bones and held in place with screws

• Screws - most common method; used by self or with other items

Treatment - Traction of the forearmInternal fixation

Cast SplintageExternal fixation

• Methods:– Plaster of Paris – Fibreglass

• Especially for distal limb # and for most children #• Disadvantage: joint encased in plaster cannot

move and liable to stiffen• Can be minimized:– Delayed splintage (traction initially)– Replace cast by functional brace after few weeks

Complications

Infection

Non-union

Implant failure

Refracture

CAUSES OF DELAYED UNION OR NON-UNION OF THE FRACTURES

Distraction & separation of the

fragments

Interposition of soft tissues between the

fragments.

Excessive movement at the fracture site

Poor local blood supply

Severe damage to soft tissues which

makes them nearly/non-viable.

Infection

Abnormal bone.

Missed fractures

• Missed fractures occurs in different reason . It could be that the doctor is inexperienced with bone fractures or the misread radiograph or the failure to obtain a radiograph.

• Poorly positioned or poorly taken radiograph may also result in diagnostic errors.

• Doctors use today diagnosing fractures are CT, MRI, Bone scan . Even a hairline fractures , stress fractures can detected those equipments

Exercise

• Prevention of edema– active exercise and elevation– Active exercise also stimulates the circulation.

Prevents soft-tissue adhesion and promotes fracture healing.

• Preserve the joint movement• Restore muscle power• Functional activity

What is a dislocation?• When the bones at a joint are no longer in proper contact.

• Can be caused by severe twisting or indirect force, or even a muscular contraction

• Most frequently dislocated joints– Shoulder– Elbow– Thumb– Finger– Jaw– Knee

Signs and Symptoms of a Dislocation

• Deformity or abnormal appearance• Pain and tenderness aggravated by movement• Loss of normal function• Joint may be locked in one position• Swelling of the joint

General Treatment Principles

• Stop the activity.

• Survey the injured area.

• First Aid if qualified.

• Get help if not.

• Determine if additional medical attention is necessary.

RICE

• R - Rest• I - Immobilize• C - Cold• E - Elevate

Shoulder Dislocation

• Take a past medical history (i.e. has this happened before?)

• Clinical exam (check for circumflex nerve function)

• X-ray to rule out possible fracture (i.e. head of the humorous)

• Several methods for reduction- Scapular rotation- Traction/counter traction

Anterior Dislocation, Right Shoulder

Glenohumeral Reductions

• Hippocratic Method1. Practitioner’s stockinged

foot is place in between the patient’s chest wall and axilla folds but not in the axilla.

2. Steady traction is maintained while the patient gradually relaxes.

3. Shoulder is slowly rotated externally and abducted.

4. Gentle internal rotation reduces the humeral head.

Posterior Elbow Dislocation

• Typical mechanism of an elbow dislocation

1. A fall backward on the arm with the elbow in a flexed position and

2. The forearm supinated is the most common mechanism.

3. The injury causes radius and ulna to dislocate posterior to the humerus.

4. There may also freq. Be an associated fracture of the radial head or

5. The coracoid process of the ulna.

Patella Dislocation

• Mechanism of Acute Dislocation

1. Typically, the patient bears weight on the slightly flexed knee

2. A sudden external rotation or twisting load to the femur causes the patella to slide superiorly over the lateral femoral condyle.

3. As the knee flexes, the patella jumps over the lateral condyle and the knee collapses.

Role of Radiographer Explain the procedure polarity and assist the pt’s to get required position. Maintain immobilization of the injured area while AP and use horizontal beam for lateral radiograph. Wise application of all radiographic skills while include appropriate positioning , exposure factors ( as much as possible high kv technique) , breathing technique. Effective communication with referring physician to achieve the best result. Best Practices in Trauma Radiography Speed Efficiency in producing quality images in the shortest possible time Accuracy Optimum image quality

Continue…

Follow universal patient transfer protocol while patient in transferred to avoid severity of the injury.

The rule for protecting the spine from further injury is to immobilize it. These precautions are the standard of care for handling a trauma patient suspected of spine injury.

Patient Preparation Use good communication skills with appropriate touch and eye contact Trauma often causes anxiety Check patient for potential artifacts Explain what you are removing and why Secure all personal effects using proper procedure for your facility

Tips to Remember

1) Updated in current radiographic imaging standards the technologist is armed with the understanding of what it is to have a high suspicion for injury that translates into safe quality patient care.

2) Radiology Technologist can make minimal diagnosis

3) Update your skills…. More in Anatomy