Professional Documents
Culture Documents
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!
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
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
1. 2. 3. 4.
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
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
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
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
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
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
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
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.