Fracture Management

Orthopedics

Treat the patient, not only the fracture

Priorities of treatment are: -first aid. -transport of the patient. -treatment of the shock & hemorrhage. -treatment of associated injuries and then treatment of the fracture itself.

Treatment of the fracture consists of: 1) Manipulation to improve the position of the fragments. 2) Splintage to hold them together until they unite.
3)Joint movement & function must be preserved. 4) Fracture healing is promoted by muscle activity and bone loading, so exercise and early weight bearing are encouraged

Reduce

Hold

Exercise

Closed Fracture
1) Reduce: - There should be no delay in attending to the fracture, because swelling of the soft parts during the first 12 hours makes reduction more difficult.
- Aim: adequate positioning and alignment of bone fragments. - Reduction is unnecessary in: 1- little or no displacement. 2- Displacement doesnt matter (e.g. some fractures of clavicle ) 3- Reduction is unlikely to succeed (e.g. compression fractures of the vertebrae)

Methods of Reduction:

1)Manipulation
2) Mechanical traction

3) Open operation

Manipulation
-Suitable for: - All minimally displaced fractures - Most fractures in children - Fractures likely to be stable after reduction
-Under anesthesia and muscle relaxation, the fracture is reduced by 3 fold maneuver: 1- The distal part of the limb is pulled in the line of the bone. 2- As the fragments disengage, they are repositioned. 3- Alignment is adjusted in each plane.

Mechanical Traction
-Used in : - Some fractures (e.g. of the femoral shaft) are difficult to reduce by manipulation because of powerful muscle pull.
- In some cases, rapid mechanical traction is applied prior to internal fixation.

Open Operation
-Indicated in : - When closed reduction failed. - Large articular fragment needs accurate positioning. - Avulsion fractures in which the fragments are held apart by muscle pull. - When the operation is needed for another injuries (e.g. arterial damage) - When a fracture will need internal fixation to hold it.

Hold
-Prevention of displacement: 1- Decrease the pain 2- Promote soft-tissue healing 3- Allow free movement of the unaffected parts

-Methods: 1- Sustained traction 2- Cast splintage 3- Functional bracing 4- Internal fixation 5- External fixation

Sustained Traction
-Traction is applied to the limb distal to the fracture, so to exert continues pull in the long axis of the bone.
-Particularly useful for spiral fracture of long bone shaft, which are easily displaced by muscle contraction -Sustained lower limb traction keeps the patient in bed for long time, thus increasing the risk of complications such as thromboembolism, respiratory problem and general weakness. - Sustained traction is best avoided in elderly patients.

Sustained Traction
1- Traction by gravity 2- Balanced traction: - Skin traction - Skeletal traction 3- Fixed traction

Traction by gravity
-Used especially in fractures of the humerus: - Weight of arm supplies the traction - Forearm is supported by wrist sling - Movement of the fracture site is reduced by applying a cast or brace to the upper part of arm

Balanced Traction
-Traction is applied to the limb, either by way of adhesive strapping which is kept in place by bandages (skin traction) or via a stiff wire or pin inserted through the bone distal to the fracture (skeletal fracture). -Skin traction will sustain a pull of no more than 4 to 5 KG. Skeletal traction can be used to apply several times as mush force, which is needed to hold lower limb fractures. Cords are attached and run over the pulleys at the end of the bed to the weights that supply the traction force -Counter traction is supplied by raising the foot of the bed and relying on the opposing weight of the patient body. The limb is supported , both for comfort and to prevent sagging at the fracture site, in a type of cradle : - Thomas s splint for the femur - Brauns frame for the tibia

Skin Traction
Complications: - Skin abrasions and allergy - Constriction of the circulation - Peroneal nerve palsy due to pressure from adhesive straps

Fixed Traction
- Same as balanced traction, but the limb is held in a thomass splint and the traction tapes are tied to the distal end of the splint while the proximal padded ring of the splint abuts firmly against the pelvis. - This method is particularly useful when the patient has to be transported.

Gallows Traction
-A type of sustained traction used to treat femoral shaft fractures in very young children.
-Skin traction is applied and the childs legs are suspended from an overhead beam, the weight of the body supplying the traction force. -There is risk that the traction taps and circular bandages may constrict the circulation, for this reason gallows traction should never be used for children over 12 KG weight.

Cast Splintage
-Plaster of Paris is still widely used as a splint specially for distal limb fracture and for most children's fractures.
-Its safe, and the speed of union is the same as traction but the patient can go home sooner. -The main drawback is joint stiffness from adhesions after swelling and hematoma resolution. -This is minimized by delayed splintage or starting with conventional cast but after a few weeks replace the cast by a conventional brace which permits joint movement.

Cast Splintage
Complications: 1- Compartment Syndrome: -Soft tissue swelling and hematoma will cause compression of the vessels and nerves with signs of ischemia. -Pain, Pallor, Pulselessness, Paralysis and Parasthesia. 2- Pressure sore: - Esp. over bony prominence. - Prevented by padding all prominent bony points before applying the cast. 3- Skin abrasion and laceration: - Esp. with removing plasters (when an electrical saw is used).

Cast Splintage
Polymer resin casts: - Cotton bandage impregnated with resin - Advantages: 1- Light 2- Rapid setting 3- Water resistance 4- Radiolucent - Disadvantages: Expensive

Functional Bracing
-Segments of a cast are applied only over the shafts of the bone, leaving the joint free, connected by metal or plastic hinges which allow movements in one plane.
-Used for fracture of the femur or tibia, or fracture begin to unite i.e. after 3-6 weeks of traction or restrictive splintage .

Internal Fixation
-Bone fragments may be fixed with screws, pins or nails, a metal plate held by screws, a long intramedullary nail, circumferential bands, or combination of these.

Internal Fixation
-Movements can begin early. -The patient can leave hospital as soon as the wound is healed. -Full weight bearing is unsafe . -The greatest danger is sepsis, if infection supervenes. -The risk of infection depends upon: 1- The patient 2- The surgeon 3- The facilities

Internal Fixation
Indications: 1- Fractures cant be reduced except by operation. 2- Unstable fractures and those prone to redisplacement after the reduction. 3- Fractures that unit poorly and slowly (e.g. femoral neck). 4- Pathological Fractures. 5- Multiple fractures. 6-Intraarticular fractures.

Internal Fixation
Types of internal fixation: 1) Screws: useful for fixing small fragments into the main bone. 2) Wires: used when fracture healing is predictably quick. 3) Plates & Screws: useful for treating metaphyseal fractures of long bone and diaphyseal fracture of the radius and the ulna. 4) Intramedullary Nails: suitable for long bones, locking screws are introduced to resist any rotational force.

-Complications:

Internal Fixation

1- Infection: The metal doesnt predispose to infection but the quality of the patients tissue and the open operation do. 2- Nonunion: - Stripping of the soft-tissue - Unnecessary damage to the blood supply in the operative fixation. - Rigid fixation with a gap between the fragments. 3- Implant failure. 4- Refracture: Its important not to remove metal implants until one year and 18-24 months safer.

5)External Fixation
- The bone is transfixed above & below the fracture with screws or pins or tensioned wires & these are clamped to a frame, or connected to each other by rigid bars.

External Fixation (continue)

-Indications: 1- Fracture associated with severe soft-tissue damage where the wound can be left open for inspection, dressing or coverage. 2- Severely comminuted & unstable fractures. 3- Fracture of the pelvis, which can't be controlled be any other methods. 4- Infected fractures, which internal fixation might not be suitable. 5- Ununited fractures, where dead fragments can be removed and the remaining ends brought together in the external fixator.

External Fixation (continue)

Complications: 1- Damage to soft-tissue structures: (pins or wires may cause damage to nerves, vessels, ligaments..) 2- Over distraction: If there is no contact between the fragments, union may be delayed or prevented. 3- Pin-track infection: This is one of the most dangerous complication.

Exercise (Mobilization)
- Reduce edema ( edema is important cause of joint stiffness)

- Stimulates the circulation so promotes fracture healing & prevents soft-tissue adhesion
- Preserve joint movement - Restore muscle power - Guide the patient back to normal activity

(communicate with the environment)

Open Fractures

Gustilos Classification
-Type I : Small clean wound (around 1 cm), with little soft-tissue damage.
-Type II : Clean wound more than 1 cm, with moderate soft-tissue damage & moderate comminution of the bone. -Type III : Extensive damage to skin, soft-tissue & neurovascular structures, with considerable contamination of the wound IIIA : Bone can be covered by soft-tissue. IIIB : Bone cant be covered by soft-tissue, there is periosteal stripping & severe comminution of the fracture. IIIC: If theres any arterial injury. --Incidence of wound infection varies from less than 2% in Type I to more than 10% in Type III.

Management of Open Fractures

1- Early wound cover at the scene of accident with sterile dressing & left undisturbed until the patient reaches the hospital. 2- In hospital rapid general assessment is the first step, then tetanus prophylaxis is administered: toxoid for those previously immunized, human antiserum if not. 3- Sterility & antibiotic cover: Second-generation cephalosporin as soon as possible for 48 hours, if wound is heavily contaminated we should cover gram by gentamicin or metranidazole for 4 days.

Management (continue)
4- Debridement & wound excision: a- Wound is flushed with normal saline b- Dead or devascularized tissues are removed c- Fascia is divided to improve muscle circulation d- after wound proves to be clean cut nerves and tendons sutured by expertise.

5- Wound closure: -Uncontaminated type I & II fractures operated within a few hours after debridement. -All other wounds must be left open, inspected every 24 hours, if the wound clean & tidy it can be sutured or skin grafted, this is called delayed primary closure

Management (continue)
6- Stabilization of the fracture: Important in reducing the likelihood of infection & assisting recovery of the soft-tissue.

Management (continue)
No obvious contamination + the time < 8 hours + Type I or Type II , treated as closed ( cast, splintage, intramedullary nail, etc)

For more severe injuries, combined approach by experienced plastic and orthopedic surgeons ( In general stabilization depend on the size and type of soft-tissue involved although external fixation using a circular frame can accommodate to most problems)

Management (continue)
Aftercare:
1- The limb is elevated and the circulation carefully monitored. 2- Antibiotic cover is continued. 3- If the wound has been left open, its inspected at 2-3 days.