Fracture treatment

A/ Reduce the fracture:Closed reductionOpen reduction

Articular fractures:Need anatomical reduction

Fracture treatment

A/ Reduce the fracture:Closed reductionOpen reduction

Articular fractures:Need anatomical reduction

Diaphyseal fracturesNeed functional reduction

Restore length, axis,

and rotation

Fracture treatment

B/ Hold reduction until healing:

Methods of holding reductionSustained tractionCast splintFunctional bracingInternal fixationExternal fixation

Fracture Management

Treatment of closed fractures

Treatment of open fractures Differe

nt

Treatment of closed fractures

Emergency care (splinting)

Definitive fracture treatment

Rehabilitationmuscle activity and early weightbearing are

encouraged

Emergency care (splinting)

Splint them where they lie

Adequate splinting is desirable

Type of splints:Improvisedconventional

Conservative

Reduction: (if displaced)under general anasthesia, the sooner the better

Steps of Reduction:TractionAlign (which fragment)Reverse mechanism of injury

Immobilization:POP (Plaster of Paris) cast, slab, traction

Rehabilitation

Closed reduction

1. Traction in the line of the bone

2. Pressing fragment into reduced position

3. Disimpaction

Absolute:when closed reduction failswhen there is an articular fragment that needs

accurate positioningfor traction (avulsion) fractures in which the

fragments are held apart

Relative:Multiple fracturesPathological fracturesTo encourage early mobilization and avoid joint

stiffness. e.g. Diaphyseal fractures

Indications of Open reduction

Type of internal fixation

Screws

Wires

Plates and screws

Intramedullary nails

Operative Vs non-operative

Criteria Operative

Non-operative

Risk of joint stiffness Low Present

Rehabilitation Rapid Slow

Risk of mal-union Low Present

Risk of non-union Present Present

Speed of healing Slow Rapid

Risk of infection Present Low

Cost ? ?

External fixation

Indications in acute trauma:Fractures associated with severe soft-tissue damage

(including open fractures) or those that are contaminated

Fractures around joints that are potentially suitable for internal fixation but the soft tissues are too swollen to allow safe surgery

Patients with severe multiple injuries

Rehabilitation

Restore function of theinjured parts and,patient as a whole

The objectives are:to reduce edema preserve joint movementrestore muscle power guide the patient back to normal activity

Treatment of open fractures

The four essentials are:Antibiotic prophylaxisUrgent wound and fracture debridementStabilization of the fracture

? External FixationEarly definitive wound cover

To be discussed separately

Complications of Fractures

Nonunion (failure to heal)3% overall50% of some particular fracturesRelated to treatment, local problems, systemic

problems (e.g. Smoking)

Complications of Fractures

Malunion: (Healing in poor position)DeformityRisk of arthritis

Complications of Fractures

Fat embolism syndromeMarrow elements (fat) released into the vascular

system and travel to the lungs Triglycerides (fat) metabolized to FFA by

pneumatocytes and these FFS are toxic to tissue Especially brain, blood vessels, kidneysARDSRisk of death

Fat Embolism

DiagnosisARDSMental status changesPetechial hemorrhageOtherTreatmentRespiratory SupportEarly recognition

Complications of Fractures

DVT/Pulmonary embolismFracture leads to immobilizationStasis, hypercoagulability, intimal injuryThrombosis of LE veinsEmbolism to heart and then lungsMechanical blockageVentilation/perfusion mismatch

DVT Prevention

MobilizationPatientLimb

MechanicalSkeletal stabilizationSCD, foot pumpsCompression

Chemical anticoagulation

Pitfalls in Fracture Management

History of mechanism of injury not obtainedCombination injury missedSoft tissue not considered

Failure to consider occult fractures

X-rays not proper; exposure, views..

Inadequate film accepted

Summary

What is a Fracture – the soft tissue part

Fracture types

Relation between fracture and force

How fractures heal

Principles of imaging

Principles of treatment

Complications of fractures