Dr. Muhammad ASIF Orthopedic Surgeon Department of Orthopaedics College of Medicine King Khalid University Hospital

Fracture management

The ideal goal of fracture management is anatomical reduction and function restoration compatible with the severity of injury, age, occupation and activity of daily living of injured patient.
 

 Either

Operative Non operative (Conservative)
 Traction  Splint (Cast / Slab)

 Traction

is the application of a pulling force to a part of the body  Purpose:

to reduce, align, and immobilize fractures;
• Unstable and unfixable

 

When reduction and/or proper length cannot be maintained by static immobilization to minimize muscle spasm to prevent or reduce skeletal deformities or muscle contractures.

Classification of Traction

Skin Traction : is maintained by direct application of a pulling force on the patient’s skin . Generally temporary measure.  To reduce muscle spasms  To maintain immobilization before surgery  In children  Skeletal Traction : applied to bone by means of a pin or wire surgically inserted into the bone,
 

providing a strong steady, continuous pull, and can be used for prolonged periods .

Osteomyelitis can occur with skeletal traction. Soft tissue injury Pin tract infection . .. Skin breakdown .Complications of traction       Neurovascular compromise. Inadequate fracture alignment.

      Pressure ulcer Pneumonia Constipation Anorexia Urinary stasis and infection Venous stasis with DVT .Complications of traction  complications from immobility especially with long term traction and in elder pt.

g. severe comminuted.General Indications for CAST 1. 7. . 5. 4. Unfixable fracture e. b. Poor bone Quality: Osteoporosis. Tremendous capacity of remodeling. Local contraindication. Systemic contraindication. Non union and stiffness is unlikely. 2. Psychosocial problem. Undisplaced fracture 3. 6. Most fractures in children: a.

To get early function  Objectives:    .Splint / Cast  Principle:  To stabilize joint above and joint below the site of injury whenever and wherever is possible To hold broken bone anatomically to prevent malunion. To reduce excessive movements to prevent non union.

 Isometric exercise.How to Preserve Function?  Immobilize only joint necessary.  Physiotherapy after cast removal.  Range of motion of uninvolved joints.  Weight bearing whenever possible in case of lower limb fracture. .

or hard part of the cast.variety of colors. hemihydrated calcium sulphate.What are casts made of ?  The outside.   Plaster (POP) .white in color. and designs. two different kinds of casting materials. patterns. On adding water it solidifies by an exothermic reaction into hydrated calcium sulphate fiberglass .  inside of the cast Cotton and other synthetic materials are used to line the inside of the cast to make it soft and to provide padding around bony areas. .

heavy must remain dry. water will distort the cast  Fiberglass    Can be used in Undisplaced Fx if swelling not expected healing process has already started. . require less maintenance. durable. Displaced Fracture that need manipulation can be molded more precisely. Plaster     is usually used in the early stages of treatment. lighter weight.

Scaphoid Fx. Also used to hold the arm or elbow muscles and tendons in place after surgery. thumb FX Humerus shaft fx Long arm Applied from the upper arm to the hand.Different types of casts Type of Cast/Slab Short arm Location Applied below the elbow to the hand. Distal humerus. Scaphoid cast/ thumb spica U slab Below elbow to hand including thumb From shoulder to elbow and then to armpit . or proximal forearm fractures. Uses Distal Forearm or wrist Fx. Also used to hold the forearm or wrist muscles and tendons in place after surgery. elbow.


From above knee to foot Proximal T/F Fx. ankle Fx. severe ankle sprains/strains.Type of Cast / Slab Location Uses Short leg cast: Applied to the area below Distal T/F Fx. trauma around knee Femur fracture in children Long leg cast Hip spica From lower chest to one or both feet From knee to foot PTB cast For weight bearing in healing Fx T/F . the knee to the foot.


Closed Reduction Method .

Remove any rings from fingers or affected limbs All acute injuries (<48 hours post injury) fully padded well molded plaster. to reduce / lock on fragments Correct rotational deformity as well. full casts may be splittted.Closed Reduction Method       Adequate analgesia / anaesthesia Traction – countertraction Increase the deformity if needed. .

After Closed Reduction and Casting  must have circulation check  Plaster takes 48 hours to become fully dry and harden so take care.  Weekly radiographs for 3 weeks to confirm acceptable reduction. .  Can re-manipulate within 3 weeks after injury if displaced.

Excellent Reduction with Well Molded Cast .

depending on shortening and displacement .Colles’ Fracture  Displaced dorsolaterrally  Treatment: Cast +/.surgery.

Scaphoid Bone FX  Retrograde blood supply  Total healing time of 10-12 weeks or more .

Boxer’s Fracture  Classically neck of the fifth metacarpal  bump over the back of palm just below the small finger knuckle  Treatment: casting or surgery (pins) .

Patellar Fracture  Fall onto kneecap or when quadriceps is contracting  Attempt “straight leg raise” If Extensor mechanism intact / undisplaced Fx Cast / Slab .

about 1-2 cm from tip. heal well in cast  Jones  Fracture  Transverse fracture through base of 5th metatarsal. cast for 6-8 wks if undisplaced .Fracture of 5th Metatarsal  Avulsion  Fracture  base of 5th metatarsal from pull of attached tendon.

Fracture of 5th Metatarsal .

Avulsion Fx .

Jones’ fracture .

30 year old patient .


metaphysis  cast for 2-4 weeks  .Torus Fracture “Buckle fracture”  mostly in children.

Type 1 S/C Fx humerus: non-displaced conservative  Note the nondisplaced fracture (Red Arrow) Note the posterior fat pad (Yellow Arrows)  .

close reduction and K-wires fixation .Type 2: Angulated/displaced fracture with intact posterior cortex.

with no contact between fragments. close / open reduction and K-Wire fixation .Type 3: Complete displacement.


Fracture surgical neck humerus. 10 year old .

Do not scratch the skin under the cast by inserting sticks. Encourage patient to move his/her fingers or toes to promote circulation . Apply an ice bag to injured area. Check for cracks or breaks in the cast. Keep the cast clean and dry.Post Cast instructions        Keep your limb elevated to prevent swelling. Rough edges should be padded to protect the skin from scratches.

Do not use the abduction bar on the cast to lift or carry the child.Contd      Prevent small toys or objects from being put inside the cast. Cover the cast while your child is eating to prevent food spills and crumbs from entering the cast. Do not put powders or lotion inside the cast. . Use a diaper or sanitary napkin around the genital area to prevent leakage or splashing of urine.

How To Know if Something Is Wrong With Your Cast         Pain that is not adequately controlled with medication prescribed by your doctor. Loosening. Increasing swelling Numbness or tingling in the extremity (hand or foot). If you develop a fever or generalized illness . Inability to move your fingers or toes beyond the cast. or wounds beneath the cast. Circulation problems in your hand or foot. splitting or breaking of the cast. sensations. Unusual odors.

muscle wasting. Plaster Sores. Malunion. Nonunion. Impaired distal neurovascular.Complications of cast        Compartment syndrome. stiff joints. Delayed union . most serious is deep venous thrombosis leading to pulmonary embolism----calf pain. Re displacement of fracture. tight cast that restricts swelling.

 Cast Burns. .can occur during cast removal if blade dull or improper technique used.

Fracture distal Radius & ulna .

Close reduction and casting .

Fracture Healed .

Fx distal Radius ulna in a Child .

After Close reduction and casting .

Angulated .One week follow up.

Surgery. close reduction and fixation .

Healed .

21 year old patient .




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