Treatment of Fractures

Prepared by: Ola Ahmad Abu-Laban 20052010056 Gp D1

Principles of Treatment
Treat the Patient, not only the fracture Treatment of the fracture:
Manipulation Splintage Joint movement and function: must be preserved Exercise and early weight bearing Main obj s = REDUCE! HOLD! EXERCISE!

The Fracture Quartet

Dual Conflict
Hold vs Move Speed vs Safety

Closed Fractures
REDUCTION
No undue delay in attending to the fracture Reduction unnecessary when:
There is little or no displacement Displacement does not matter Reduction is unlikely to succeed

Aim of reduction
Adequate apposition Normal alignment of the bone fragments

Methods of reduction
Manipulation Mechanical traction Open operation

1. Manipulation
Closed manipulation is suitable for
1. All minimally displaced fractures 2. Most fractures in children 3. Fractures that are likely to be stable after reduction

Unstable fractures are sometimes reduced closed prior to mechanical fixation Three fold maneuver: under anesthesia and muscle relaxation
1. The distal part of the limb is pulled in the line of the bone 2. The fragments are repositioned as they disengage 3. Alignment is adjusted in each plane

2. Mechanical Traction
Some fractures are difficult to reduce by manipulation They can often be reduced by sustained mechanical traction, which then serves also to hold the fracture until it starts to unite In some cases, rapid mechanical traction is applied prior to internal fixation

3. Open Operation
Operative reduction under direct vision is indicated: 1. When closed reduction fails 2. When there is a large articular fragment that needs accurate positioning 3. For avulsion fractures in which the fragments are held apart by muscle pull 4. When an operation is needed for associated injuries 5. When a fracture will anyhow need internal fixation to hold it

Hold
Restriction of movement
Prevention of displacement Alleviation of pain Promote soft-tissue healing Try to allow free movement of the unaffected parts

Splint the fracture, not the entire limb Methods of holding reduction:
Sustained traction Cast splintage Functional bracing Internal fixation External fixation

Closed vs. operative methods

1. Sustained Traction
Traction is applied to the limb distal to the fracture, so as to exert a continuous pull in the long axis of the bone In most cases a counterforce will be needed Particularly useful for spiral fractures of long-bone shafts, which are easily displaced by muscle contraction The hold is not perfect, but it is safe and the patient can move the joints and exercise the muscles. The problem is the lack of speed complications

 Traction by gravity
Eg. Fractures of the humerus

Balanced Traction
Skin traction: adhesive strapping kept in place by bandages Skeletal traction: stiff wire/pin inserted through the bone distal to the fracture

Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.

2. Cast Splintage
Plaster of Paris: still used as splint, esp for distal limb fractures and for most children s fractures safe (not applied too tightly or unevenly) speed of union same as traction, but pt goes home sooner holding is not a problem, and patients with tibial fractures can bear weight on the cast Big drawback is that joints encased in plaster cannot move and are liable to stiffen. This complication can be minimized by:
1. 2. Delayed splintage- using traction until movement has been regained, and then applying plaster Starting with a cast but after a few weeks replacing it by a functional brace which permits joint movement

 Complications of cast splintage

Liable to appear once the patient has left the hospital; added risk of delay before the problem is attended to

1. 2. 3. 4.

Tight cast Pressure sores Skin abrasion or laceration Loose cast

3. Functional Bracing
Prevents joint stiffness while still permitting fracture splintage and loading Most commonly for fractures of the femur or tibia Since its not very rigid, it is usually applied only when the fracture is beginning to unite
Comes out well on all four of the basic requirements: hold move speed safe

4. Internal Fixation
holds securely with precise reduction movements can begin at once (no stiffness and edema) speed : patient can leave hospital as soon as wound is healed, but full weight bearing is unsafe for some time safety = biggest problem! SEPSIS!!!
Risk depends on: the patient, the surgeon, the facilities

 Indications for internal fixation

1. Fractures that cannot be reduced except by operation 2. Fractures that are inherently unstable and prone to re-displacement after reduction 3. Fractures that unite poorly and slowly 4. Pathological fractures 5. Multiple fractures 6. Fractures in patients who present severe nursing difficulties

1. Interfragmentary/Lag Screws: o Fixing small fragments onto the main bone

3. Plates and screws o Metaphyseal fractures of long bones o Diaphyseal fractures of the radius and ulna

2. Kirschner Wires o Hold fragments together where fracture healing is predictably quick

4. Intramedullary nails o Long bones o Locking screws resist rotational forces o T

 Complications of internal fixation

Most are due to poor technique, equipment, or operating conditions Infection
Iatrogenic infection is now the most common cause of chronic osteomyelitis

Non-union
Excessive stripping of the soft tissues unnecessary damage to the blood supply in the course of operative fixation rigid fixation with a gap between the fragments

Implant failure Refracture

5. External Fixation
Permits adjustment of length and angulation Some allow reduction of the fracture in all 3 planes. Especially applicable to the long bones and the pelvis. Indications:
1. 2. 3. 4. 5. 6. Fractures associated with severe soft-tissue damage where the wound can be left open for inspection, dressing, or definitive coverage. Severely comminuted and unstable fractures, which can be held out to length until healing commences. Fractures of the pelvis, which often cannot be controlled quickly by any other method. Fractures associated with nerve or vessel damage. Infected fractures, for which internal fixation might not be suitable. Un-united fractures, where dead or sclerotic fragments can be excised and the remaining ends brought together in the external fixator; sometimes this is combined with elongation in the normal part of the shaft

 Complications of external fixation

High degree of training and skill! Often used for the most difficult fractures increased likelihood of complications

Damage to soft-tissue structures Over-distraction

No contact between the fragments union delayed/prevented

Pin-track infection

Exercise
Restore function to the injured parts and the patient as a whole Active Exercise, Assisted movement (continuous passive motion by machines), Functional activity Objectives:
Restore circulation Prevent soft tissue adhesions Promote fracture healing Reduce edema
Swelling tissue tension and blistering, joint stiffnes Soft Tissue care: elevate and exercise, never dangle, never force

Preserve joint movement Restore muscle power Guide patient back to normal activity

OPEN FRACTURES
Initial Management
At the scene of the accident In the hospital

Types of Open Fractures

Gustilo s classification of open fractures:
Type 1: low-energy fracture with a small, clean wound and little softtissue damage Type 2: moderate-energy fracture with a clean wound more than 1 cm long, but not much soft-tissue damage and no more than moderate comminution of the fracture. Type 3: high-energy fracture with extensive damage to skin, soft tissue and neurovascular structures, and contamination of the wound.
Type 3 A: the fractured bone can be adequately covered by soft tissue Type 3 B: can t be adequately covered, and there is also periosteal stripping, and severe comminution of the fracture Type 3 C: if there is an arterial injury that needs to be repaired, regardless of the amount of other soft-tissue damage.

- The incidence of wound infection

- correlates directly with the extent of soft-tissue damage, <2% in type 1 >10% in type 3 - rises with increasing delay in obtaining soft tissue coverage of the fracture.

Principles of Treatment of Open Fractures

All open fractures assumed to be contaminated Prevent infection! The essentials:
Prompt wound debridement Antibiotic prophylaxis Stabilization of the fracture Early definitive wound cover Repeated examination of the limb because open fractures can also be associated with compartment syndrome

Sterility and Antibiotic cover

The wound must be kept covered until the patient reaches the operating theatre Antibiotics ASAP Most cases: Benzylpenicillin and flucloxacillin Even better: 2nd generation cephalosporin, every 6 hrs/48 hrs If heavily contaminated, cover for Gram (-) organisms and anaerobes by adding gentamicin or metronidazole and continuing treatment for 4 or 5 days

Debridement and Wound Excision

In the operating theatre, never in the ER! Under GA Maintain traction on injured limb and hold it still Remove clothing Replace dressing with sterile pad Clean and shave surrounding skin Remove pad and irrigate wound with A LOT of warm normal saline Do not use a tourniquet! Extend wound and excise ragged margins healthy skin edges Remove foreign materials and tissue debris Wash out wound again with warm NS (6-12 L) Remove devitalized tissue Best to leave cut nerves and tendons alone

Wound Closure
to close, or not to close the skin= difficult decision
Uncontaminated types 1 and 2 wounds may be sutured All other wounds: delayed primary closure Type 3 wounds may occasionally have to be debrided more than once and skin closure may call for plastic surgery. Skin grafting= most appropriate if the wound cant be closed w/o tension and the recipient bed is clear, free of obvious infxn, and well vascularized

Stabilization of the Fracture

Stability of the fracture is imp in
Reducing the likelihood of infxn Assisting in recovery of the soft tissues

Method of fixation depends on:

Degree of contamination Length of time from injury to operation Amount of soft tissue damage

Open fractures of all grades up to 3A treated as for closed injuries More severe injuries: combined approach by plastic and ortho surgeons
The precise method depends on the type of soft-tissue cover that will be employed, although external fixation using a circular frame can accommodate to most problems

Aftercare and Team Work

Post-op
Limb is elevated Circulation carefully monitored Antibiotic cover continued; swab samples will dictate whether a diff. antibiotic is needed If wound has been left open, inspect in 2-3 days. Delayed primary suture is then often safe or, if there has been much skin loss, plastic surgery for grafting may be necessary

Teamwork
For optimal results, open fractures with skin and soft-T damage are best managed by a partnership of ortho and plastic surgeons, ideally from the outset rather than by later referral If no plastic surgeon on site, use a digital camera for image transmission by internet to communicate and consult.