Treatment of fractures and dislocations
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GROUP 1 Treatment of Fractures and DislocationsDr.Vekariya kushal N.
The majority of fractures are managed non surgically.
OPTIMAL TREATMENT DEPEND
location and type of fractureIn some instances (such as a minimally displaced fracture of the middle phalanx of one of the lesser toes) no treatment at all other than those for symptoms of pain generally are necessary
some form of immobilization treatment
Patient with splint on hand Patient with sling arm
Patient with clavicle brace
Patient with broken finger or phalanges
Spinal braceShoulder brace
In When more complete immobilization is desired, immobilization in a circumferential plaster or fiberglass cast is often ideal.
A proper cast is carefully constructedTo immobilize the fractured bone and avoid the complications of loss of reductionneurovascular compromise pressure ulceration of skinthe creation of joint contractures. Non displaced fractures generally are treated by simple casting
Should the fracture be unacceptably displaced, a closed reduction to realign the bones precedes the application of the cast
This often requires local, regional, or systemic anesthesia.To construct a castfirst covered with a cloth sleeve or stocking. Critically, the limb is then covered with a generous amount of cast padding
Insufficient padding, particularly overlying a bony prominence, can cause skin erosion within the immobilizing cast, a potentially devastating complication.
After adequate padding is in place, plaster or fiberglass is gently rolled on to the limb. The cast material is applied wet and will generate heat while hardeningPatients can sustain burns during application of thick casts or splints. Several minutes are required, and for this reason, it is applied in layers while maintaining reduction of the fracture.
This is superior to plaster in terms of strength to weight ratio and has largely replaced plaster for many casting applications. Fiberglass tape itself it is a bit elastic and creates an extra potential hazard of creating a cast too tight. This can lead to excessive compression to the limb.
Fiberglass cast tape
In minimally displaced fractures, a circumferential plaster or fiberglass cast can be safely applied immediately.
other injuries, definitive casts are applied 24 to 72 hours after the acute injury because of the potential for ongoing swelling beneath the cast, which all too frequently results in skin problems or neurovascular compromise.
Generally, the cast application, particularly if the casting involves reduction maneuvers, are followed by immediate postprocedure x-ray imaging, to verify a satisfactory alignment of the fracture fragments.
Internal fixation refers to any device placed surgically to directly hold bones in position. These can include sutures, wires and screws, plates, rods, or nails. Internal Fixation
Many times simply fixing two fractured bones together using individual screws can be effective. The surgeon must choose an appropriate sized screw and place it correctly with good purchase on the bone. Bone screws come in a variety of designs to address specific fracture fixation problems.
Simple Screw Fixation
A cortical screw is a screw with a large inner diameter and shallow screw threads. This screw is designed to have a high breaking strength for its total diameter, and the screws threads are intended to engage cortical bone. Purchase of shallow screw threads in cortical bone can be excellent.
Cancellous screws have a deeper thread pattern and a smaller inner shaft diameter.
They are designed to obtain fixation in less dense cancellous bone. Lag screws also are commonly used.
These are screws in which only the distal portion of the screw length is threaded. These screws penetrate one bone fragment without thread fixation.
When a second fracture fragment is engaged by the threaded portion of the screw, turning the screw head tight down to the cortex of the first bony fragment will pull or "lag" the distal fragment toward the screw head. Compression of the fractured bones is the result.
Fractures of long bones are managed by intramedullary rods or nails. A metal rod is inserted into the medullary canal to obtain a tight and secure fit to immobilize the fracture. Often, as in the femur, the medullary canal is sequentially reamed over a guide wire to allow insertion of a stout rod. Frequently, the rod is further stabilized by inserting "locking screws" that transfix the bone cortex and pass through appropriate holes in the rod either distal, proximal, or bothIntramedullary Internal Fixation
fractures of the bone usually do not occur with penetration of the skin.
A more serious condition exists when the fracture hematoma communicated with a wound of the skin. Such injuries are called open fractures.
open fracture implies communication between external environment and the fracture.
soft tissue injury complicated by a broken bone.
Penetrating trauma also can lead to open fractures, and bacterial contamination must be assumed to be present in all cases.
All injury carry serious risk of Infection and ostiomlaytisOpen fracture treated by Formal irrigation and debridement procedure perform in operating room
Depending on the circumstances of each individual injury, the initial debridement can be followed by simple splinting, or external fixation (with definitive operative treatment performed at a later date), or by definitive internal fixation.
In severe injuries, with extensive soft tissue injury, the fracture treatment usually is performed in stages.
it is a clinical emergency and describes a clinical situation where muscle tissue compartment edema constrained by the investing muscle fascia results in increased muscle compartment pressures sufficient to stop small vessel flow of blood.
Severe problems arise when the profusion pressure in the capillary bed is approached or exceeded by the intracompartmental pressure. In this situation, perfusion of the muscle is compromised and muscle necrosis results.
The diagnosis of a compartment syndrome is a clinical one, based on complaints of local pain out of proportion to the apparent injury, in association with pain, on passive stretch of the involved muscles.
This situation can arise after a period of ischemia, after local blunt trauma and in the presence of an acute fracture.
Measurement of compartment pressures, using one of a number of commercially available devices, involves inserting a needle into the suspected muscle compartments to measure pressure.
Pressure measurements alone are not reliable to absolutely rule in or rule out the diagnosis, but they can be a useful adjunct to clinical assessment, particularly valuable in obtunded or unconscious patients.
Pressure measurements that are greater than 30 mmHg or within 30 mmHg of the diastolic blood pressure are consistent, but not absolutely diagnostic with the presence of a compartment syndrome.
Treatment of a compartment syndrome is always surgical and involves extensive skin incisions and fascial release of all suspected muscle compartments.
An untreated compartment syndrome will result in necrosis of involved muscle compartments with subsequent contracture and severe loss of function in the affected limb.
Surgical Extensive skin incisionsFascial release of all suspected muscles (fasciotomy)
Performing fasciotomy on patient with compartment syndrome