Treatment of Fractures

Prepared by:Ola Ahmad Abu-Laban

20052010056Gp 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 for1. All minimally displaced fractures2. Most fractures in children3. 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 relaxation1. The distal part of the limb is pulled in the line of the bone2. The fragments are repositioned as they disengage3. 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 fails2. When there is a large articular fragment that needs

accurate positioning3. For avulsion fractures in which the fragments are held

apart by muscle pull4. When an operation is needed for associated injuries5. 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. Delayed splintage- using traction until movement has been

regained, and then applying plaster2. 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.Tight cast2.Pressure sores3.Skin abrasion or laceration 4.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 fixation1. Fractures that cannot be reduced except by

operation2. Fractures that are inherently unstable and prone to

re-displacement after reduction3. Fractures that unite poorly and slowly4. Pathological fractures5. Multiple fractures6. Fractures in patients who present severe nursing

difficulties

1. Interfragmentary/Lag Screws:o Fixing small

fragments onto the main bone

2. Kirschner Wireso Hold fragments together where

fracture healing is predictably quick

3. Plates and screwso Metaphyseal

fractures of long bones

o Diaphyseal fractures of the radius and ulna

4. Intramedullary nailso Long boneso Locking screwsresist 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. Fractures associated with severe soft-tissue damage where the wound can be left open for inspection, dressing, or definitive coverage.

2. Severely comminuted and unstable fractures, which can be held out to length until healing commences.

3. Fractures of the pelvis, which often cannot be controlled quickly by any other method.

4. Fractures associated with nerve or vessel damage.5. Infected fractures, for which internal fixation might not be suitable.6. 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

• Swellingtissue 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 soft-tissue 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.