FRACTURE MANAGEMENT

Treatment of Fractures

•Phase I - Emergency care

a) at the site of accident
b) at the emergency department
•Phase II - Definitive care

•Phase III - Rehabilitation of a fractured limb

 PHASE I - EMERGENCY CARE

A. At the site of accident: RICE

 Rest to the part, by splinting
 Ice therapy, to reduce swelling
 Compression, to reduce swelling
 Elevation, to reduce swelling
Splinting
 'Splint them where they lie’.
 Almost any available object at the site of
the accident can be used for splinting.
 One may correct any gross deformity by
gentle traction.
 Feel for distal pulses, and do a quick
assessment of vascular supply before and
after splinting.
 The advantages of splinting are:
• Relief of pain, by preventing movement at
the fracture.
• Prevention of further damage to skin, soft
tissues and neurovascular bundle of the injured
extremity.
• Prevention of complications such as fat
embolism and hypovolaemic shock.
• Transportation of the patient made easier.
B. In the emergency department:

 Basic life support (BLS). (ABC)

 Rule out head injury, chest injury and abdominal injury
If in shock, the patient is stabilised before any definitive
orthopaedic treatment is carried out.
 The fractured limb is examined to exclude injury to
nerves or vessels.
 Any bleeding is recognised and stopped by local pressure.
(open fractures)
 Once patient is stablised, the limb is splinted
PHASE II - DEFINITIVE CARE

 Philosophy of fracture treatment:

 The aim is to get the limb function back to pre-injury level.
 the three fundamental principles of fracture treatment:
 Reduction : closed reduction ,continuous traction,open reduction
 immobilisation :
Non operative – (strapping ,plaster of paris cast, functional bracing ,splints and
traction)
Operative methods – (internal fixation and external fixation )
 preservation of functions.
 REDUCTION OF FRACTURES

 TYPES ARE :
a) Closed manipulation and reduction (CMR):
 This is the standard initial method of reducing most
fractures.
 It is usually carried out under anaesthesia and
requires experience.
 The availability of an image intensifier has greatly
added to the skills of closed reduction.
 Most fractures reduced by closed manipulation need
some kind of immobilisation (PoP, brace, bandaging
etc.)

C arm
 b) Continuous traction:
 It is used to counter the muscle forces which
will not allow reduction to happen or would
cause redisplacement.
 E.g., Inter-trochanteric fracture femur.
 complications such as bedsores ,DVT
c) Open reduction: In this method, the fracture is surgically exposed, and the fragments are
reduced under vision.
 Some form of internal fixation is used in order to maintain the position.
 This is commonly referred as 'open reduction and internal fixation' or ORIF.
 IMMOBILISATION OF FRACTURES
 The reasons for immobilising a fracture may be:
a) Prevent displacement or angulation
b) To prevent movement that might interfere with the union: Persistent
movement might tear the delicate early capillaries bridging the fracture.
More strict immobilisation is necessary for some fractures (e.g., scaphoid
fracture).
c) To relieve pain: This is the most important reason for the immobilisation of
most fractures. As the fracture become pain free and feels stable, guarded
mobilisation can be started.
 NON OPERATIVE :

 strapping (phalanx fracture)

 sling (fracture clavicle)

 plaster of paris cast

 functional bracing

 Splints and tractions

 OPERATIVE METHODS :
 Internal fixation
 In this method, the fracture, once reduced, is held internally with screw, plate, Kirschner wire (K-
wire), intra-medullary nail etc.
 External fixator:
 It is a device by which the fracture is held in a
steel frame outside the limb.
 For this, pins are passed percutaneously to
hold the bone, and are connected outside to a
bar with the help of clamps.
 This method is useful in the treatment of open
fractures where internal fixation cannot be
carried out due to risk of infection.
 These are of the following type:
i. Pin fixators
ii. Ring fixators
PHASE III - REHABILITATION OF A
FRACTURED LIMB
 Rehabilitation of a fractured limb begins at
the time of injury, and goes on till
maximum possible functions have been
regained.
 It consists of
 joint mobilization (passive and active )
 muscle strengthening exercises (static
contractions and dynamic contractions )
 weight bearing and gait training.
 Emergency
dept

Accident site Long leg cast

Nailing

Rehabilitation
OPEN FRACTURES
MANAGEMENT OF OPEN FRACTURES
Gustilo and Anderson classification of
open tibia fractures

 Type 1 – less than 1cm

 Type 2 – more than 1cm -10cm
 Type 3 – more than 10cm
 3A – Adequate soft tissue coverage
 3B – Bone exposed
 3C –Circulation impaired
MANAGEMENT OF OPEN FRACTURES

 Three consequences from open fracture

a) Infection of bone: Contamination of the wound with bacteria from the outside
environment may lead to infection of the bone (osteomyelitis).

b) Cant use traditional methods of immobilisation:

 Plaster cast
 The presence of a wound may also be a deterrent to operative fixation of the
fracture.
c) Problems related to union:
 Non-union and malunion occur commonly in
open fractures.
 Due to one or more of the following reasons:
(i) a piece of bone may be lost from the wound at
the time of the fracture, the gap thus created
predisposes to non-union;
(ii) the fracture haematoma, which is supposed to
have osteogenic potential, is lost from the wound;
(iii) the 'vascular' cover by the overlying soft tissues,
so important for fracture union, may be missing; and
(iv) the bone may get secondarily infected, and thus
affect union.
Phase I - Emergency Care

 At the site of accident:

a) If active bleeding from the wound  apply firm pressure using a clean piece
of cloth.
b) The wound is washed with clean tap water or saline, and covered with a clean
cloth.
c) The fracture is splinted.
 In the emergency department:
a) Wound care:
Saline or clean water wash and cover it with sterile dressing.
A piece of bone with intact soft tissue attachments hanging out of the wound,
should be washed and put back in the wound.
b) Splintage
c) Prophylactic antibiotics.
d) Tetanus prophylaxis
e) Analgesics
f) X-rays ,CT scan
Phase II - Definitive Care :
 orthopaedic surgeons  fracture treatment
 plastic surgeon  exposed bone coverage (skin grafting,flap reconstruction)
 vascular surgeon  repair of damaged vessels

 Wound care:
A) wound debridement
B) definitve wound management
 Fracture management :
a) Immobilisation in plaster: For cases with moderate size
wound (TYPE 1 OR TYPE 2)
b) External fixation
c) internal fixation (INTRAMEDULLARY NAILING)
Phase III - Rehabilitation

 joint mobilisation,
 muscle strengthening exercises
Complications of open fractures
 Emergency dept
Accident site

External fixation

Intramedullary
Nailing

Rehabilitation
Type 1 or 2 Type 2 or 3
 PLASTER OF PARIS
 FUNCTIONAL BRACING
 ILIZAROV FIXATOR
PLASTER OF PARIS
.
 Plaster-of-Paris casts have been in use for a long time.
 Plaster of Paris (Gypsum salt) is CaSO4.½ H2O (calcium sulphate hemihydrate)
in dry form, which becomes CaSO4.2H2O (calcium sulphate dihydrate) on
wetting.
 This conversion is an exothermic reaction and is irreversible.
 The plaster sets in the given shape on drying.
 The setting time of a plaster varies with its quality, and temperature of the
water
• Types of plaster bandages:

 home-made bandages : One prepared by impregnating

rolls of starched cotton bandages with plaster powder

 readymade bandages
 Use of Plaster of Paris:
 Slab :
 A plaster slab covers only a part of the
circumference of a limb.
 The slab is used for the immobilisation of soft
tissue injuries and for reinforcing plaster casts.
 Cast
 covers the whole of the circumference of a limb
 Some of the fundamental principles to be remembered while applying a
plaster cast are as follows:
• Immobilise the joints above and below the fracture.
• Immobilise joints in a functional position.
• Pad the limb adequately, especially on bony prominences.
 After care of a plaster:
 Check for any cracks in the plaster
 avoiding wetting the plaster,
 graduated weight bearing for lower limb fractures.
 Exercising the muscles within the plaster and
moving adjacent joints is necessary to ensure early
recovery.
 Complications of plaster treatment:
•Impairment of circulation (tight cast)
 Since plaster cast is a closed compartment
Haematoma and tissue oedema following a
fracture can result in increased pressure
inside the cast, leading to impaired
circulation of the extremity.
 Unrelenting pain, especially stretch pain,
swelling over the fingers, inability to move
the fingers, hypoaesthesia and bluish
discolouration of the digits are signs of a tight
cast.
 A tight cast can be prevented by adequately
padding the cast and elevating the extremity
for the first 2-3 days following a cast
application.
• Plaster sores:
o These are caused by inadequate padding, irregularity of the inner surface
of the cast, or foreign bodies in the plaster. A sore formation within a
plaster cast can be suspected by the following:
o • Pain, out of proportion to fracture
o • Fretfulness
o • Disturbed sleep
• Recurrence of swelling over toes or fingers
• Low grade fever
• Patch of blood/soakage over the cast.