PRINCIPLES OF FRACTURE

TREATMENT & PRIORITIES IN

POLYTRAUMA PATIENT

BENJAMIN MUKULU NDELEVA

M.MED (ORTHO), FCS ECSA
 OBJECTIVE

Discuss the broad principles of

fracture treatment (applied to all
fractures with suitable adjustments)
 OUTLINE
 Initial Management – ATLS principles
 Hx and Examination
Signs/symptoms of fractures/dislocations
 General Principles - Reduce, Hold, Rehab
 Non-operative Rx
 Operative Rx
 Open Fractures
 Priorities in Polytrauma
 INITIAL MANAGEMENT
 At scene of Injury

 ATLS principles A – Airway & C-spine

B – Breathing
C – Circulation

 Temporary Splintage

 Transport
 AIRWAY & C SPINE
 Ensure that the airway is open

 Jaw thrust or Chin lift manouvre

 Clear airway of FBs/secretions

 If C Spine Injury suspected, support C spine

with a rigid cervical collar
 BREATHING
 Ensure pt “moving air” adequately as
evidenced by :
- Chest movements
- Audible “hiss”
- Pulse auximetry
 Check for flail chest segment/evidence of
tension pneumothorax

 Bag & mask, Intubation+Ventilation as

necessary
 CIRCULATION
 Check pulse/BP

 Arrest any obvious haemorrage

 2 large bore IV cannulars & get blood for GXM

 Fluid resuscitation

 Blood as indicated
 TEMPORARY SPLINTAGE
 All suspected fractures should be splinted stat
at site of injury to : - relieve pain
- protect soft tissues
- prevent embolism
 Use available material
 Opposite lower limb
 Strap arm to chest
 Hold limb in “best” position possible
 TRANSPORT
 Apply longitudinal traction as you move

 Log roll if spine injury suspected

 Transport ASAP to nearest adequately

equipped health facility
 Hx / Examination
 In hospital, repeat ATLS protocal

 Hx/PE/Inx – refer to earlier lecture

 AIM – Establish ALL injuries present

- Set priorities in Mx
- Institute Mx ASAP
GENERAL # Rx PRINCIPLES
PRINCIPLE - REDUCE

- IMMOBILIZE

- REHABILITATE
 REDUCTION
 If necessary
 Indications for Reduction - Displacement
(Translation, Angulation, Shortening)
 Not indicated for #s below
 METHODS OF REDUCTION
 Manipulation

 Traction

 Open reduction
 MANIPULATION
 Under GA, Regional/Local anaesthesia
 Adequate anaesthesia/relaxation important

 Technique - Grab fragment thru soft tissue

- Disimpact
- Reverse displacement
(Correct/restore length , rotation &
angulation)
 Variation depending on site
 Closed Reduction Principles
 Reduction may require reversal of mechanism of injury
 When the fracture breaks because of bending, the soft tissues
disrupt on the convex side and remain intact on the concave side
 Closed Reduction Principles
 Longitudional traction may not allow the fragments
to be disimpacted and brought out to length if there
is an intact soft-tissue hinge (typically seen in
fractures of the distal radius and ulna in children)
 Closed Reduction Principles
 Reproduction of the mechanism of fracture to hook
on the ends of the fracture
 Angulation beyond 90° is usually required
 TRACTION
 Commonly applied for # Femur & C Spine

 Rapid (Under GA) or Gradual (over time)

 Skin Vs Skeletal

 Fixed Vs Continuous
 OPEN REDUCTION
Indications

 Failed closed reduction

 Displaced Articular fractures

 Accompanying neurovascular injury

Usually followed by internal fixation

 IMMOBILIZATION
 If necessary
 Indications - Prevent loss of reduction
- Prevent excessive motion
- Relieve pain
 #s always needing immobilization – Scaphoid,
Ulna, Neck of Femur)
 #s not requiring immobilization – Ribs,
Scapula, Clavicle
 IMMOBILIZATION
 Discontinue at the earliest practical time

 Especially unforgiving are:

- Hand
- Elbow
- Shoulder
 METHODS OF IMMOBILIZATION
 Cast – (POP, Dynacast)

 Prefabricated Splints

 Continuous Traction

 External Fixation

 Internal Fixation
 CAST IMMOBILIZATION
 May use POP or fibre glass derivatives
 CASTING
 Goal of semi-rigid immobilization while
avoiding pressure / skin complications

 Often a poor choice in the treatment of acute

fractures due to swelling and soft tissue
complications

 Good cast technique necessary to achieve

predictable results
 Casting Techniques

 Cast padding
 Roll distal to proximal
 50 % overlap
 2 layers minimum
 Extra padding at pressure
points (fibular head,
malleoli, patella, and
olecranon) Figure from Chapman’s
Orthopaedic Surgery 3rd Ed.
 Plaster vs. Fiberglass
 Plaster
 Use cold water to maximize molding time
 Fiberglass
 More difficult to mold but more durable and
resistant to breakdown
 Generally 2 - 3 times stronger for any given
thickness
Cast Molding
• Avoid molding with
anything but the heels of
the palm in order to avoid
pressure points
• Mold applied to produce
three point fixation

Figure from Chapman’s

Orthopaedic Surgery 3rd Ed.
 Complications of Casts & Splints
 Loss of reduction
 Pressure necrosis – may occur as early as 2
hours
 Tight cast  compartment syndrome
Univalving = 30% pressure drop
Bivalving = 60% pressure drop
Also need to cut cast padding
 Complications of Casts & Splints
 Thermal Injury - avoid plaster > 10 ply, water
>24°C
 Cuts and burns during removal
 DVT/PE - increased in lower extremity
fracture
 Ask about prior history and family history
 Indications for prophylaxis debated
 Joint stiffness
 Leave joints free when possible (ie. thumb MCP for
below elbow cast)
 Place joint in position of function
 TRACTION
 Allows constant controlled force for initial
stabilization of long bone fractures as well as
maintaining reduction

 Option for skeletal vs. skin traction is case

dependent
 Skin Traction
 Limited force can be applied - generally not to
exceed 10 lbs

 More commonly used in pediatric patients

 Can cause soft tissue problems especially in

elderly or rheumatoid patients

 Not as powerful when used during operative

procedure for both length or rotational
control
 Skeletal Traction
 More weight can be applied cf to skin traction

 Up to 20 % of body weight for the lower

extremity

 Requires local anesthesia for pin insertion if

patient is awake

 Preferred method of temporizing long bone,

pelvic, and acetabular fractures until operative
treatment can be performed
 Traction Pin Types
 Choice of thin wire vs. Steinman pin
 Thin wire is more difficult to insert with hand
drill and requires a tension traction bow

Standard Bow Tension Bow

 Traction Pin Types
 Steinmann pin may be either smooth or
threaded
 Smooth is stronger but can slide if angled
 Threaded pin is weaker, bends easier with higher
weight, but will not slide and will advance easily
during insertion
 In general the largest pin available is chosen,
especially if a threaded pin is selected
 Traction Pin Placement
 Sterile field
 Local anesthesia + sedation
 Insert pin from known area of neurovascular
structure
 Distal femur: Medial  Lateral
 Proximal Tibial: Lateral  Medial
 Calcaneus: Medial  Lateral
 Place sterile dressing around pin site
 Place protective caps over sharp pin ends
 SKULL TRACTION
 Used for C-spine reduction / traction

 Gardner Wells Tongs

 Pins are placed one finger breadth above pinna,

slightly posterior to external auditory meatus

 Apply traction beginning at 5 lbs. and increasing

in 5 lb. increments with serial radiographs and
clinical exam
 HALO & VEST
 Indicated for certain cervical fractures as
definitive treatment or supplementary
protection to internal fixation

 Disadvantages
 Pin problems
 Respiratory compromise
HALO & VEST
EXTERNAL FIXATION
 Indications
 Definitive fx care:  Malunion/nonu
 Open fractures nion
 Peri-articular fractures  Arthrodesis
 Pediatric fractures  Osteomyelitis
 Temporary fx care  Limb
 “Damage control” deformity/lengt
 Long bone fracture
h inequality
temporization
 Pelvic ring injury
 Periarticular fractures
 Advantages

 Minimally invasive
 Flexibility (build to fit)
 Quick application
 Useful both as a temporizing or definitive
stabilization device
 Reconstructive and salvage applications
 Disadvantages

 Mechanical
 Distraction of fracture site
 Inadequate immobilization
 Pin-bone interface failure
 Weight/bulk
 Refracture (pediatric femur)
 Biologic
 Infection (pin track)
 May preclude conversion to internal fixation
 Neurovascular injury
 Tethering of muscle
 Soft tissue contracture
Components of the Ex-fix

 Pins

 Clamps

 Connecting rods
 Pins
 Various diameters,
lengths, and designs

 Materials
 Stainless steel
 Titanium
 Clamps
 Mustsecurely hold the
frame to the pin

 Clamps placed closer to

bone increases the
rigidity of the entire
fixator
 Connecting Rods and/or Frames
 Materials:
 Steel
 Aluminum
 Carbon fiber
 Design
 Simple rod
 Articulated
 Telescoping
 Principle: increased diameter = increased rigidity and
strength
 Principle: double stack = increased rigidity
 Frame Types
 Uniplanar
 Unilateral
 Bilateral
 Pin transfixes
extremity
 Biplanar
 Unilateral
 Bilateral
 Circular (Ring
Fixator)
 Half-pins vs. transfixion
wires
 Hybrid Unilateral uniplanar Unilateral
biplanar
 Combines rings with
planar frames
 Ring Fixators

 Components:
 High tension thin
wires
 olive or straight
 Wire and half pin
clamps
 Rings
 Rods
 Ring Fixators
 Principles:
 Multiple tensioned thin wires
(90-130 kg)
Place wires as close to 90
o

to each other
 Half pins also effective
 Use full rings (more difficult to
deform)
 Can maintain purchase
in metaphyseal bone
 Allows dynamic axial
loading
 May allow joint motion
Multiplanar Adjustable Ring Fixators
 Adjustable with 6 degrees of
freedom
 Deformity correction
 Hybrid Fixators
 Combines the
advantages of ring
fixators in
periarticular areas
with simplicity of
planar half pin
fixators in
diaphyseal bone

From Rockwood and Green’s, 5th Ed

 INTERNAL FIXATION
INDICATIONS
- Poly trauma – so other injuries can be
attended to (head, thorax, abdomen)

- Certain #s –i.e Intertroch, forearm

- Failed closed red/immobilisation

METHODS FOR INT’ FIXATION
 Plate & Screws

 Intramedullary nail

 Dynamic compression Screw-plate

 Condylar Screw-plate

 Wires i.e. Tension Band wiring

 Screws
• Cortical screws:
– greater surface area of
exposed thread for any given
length
– better hold in cortical bone
• Cancellous screws:
– core diameter is less
– the threads are spaced
farther apart Figure from: Rockwood and Green’s, 5th
– lag effect option with ed.

partially threaded screws

– theoretically allows better
fixation in soft
cancellous bone.
 Plates
• Plate designs - Compression Plates
- Low contact plates
- Reconstruction plates

• Plates can be - Bridging plate

- Buttress plate
- Neutralizing plate
- Tension band plate
-
 Lag Screw Fixation
 Screw tensioned
across fx =
compression of fx
 Terminal threads
and smooth shank
OR
 Overdrill near
cortex & engage
only far cortex
 Tension Band Principle
 Eccentric Tension force converted to
compressive force on the opposite side

 Can be done using wires, screws & wires or

plate and screws

 Commonly used at - Patella

- Olecranon
- Proximal femur
Classic Tension Band of the Olecranon

• 2 K-wires up the ulnar shaft

maintain initial reduction
and anchor for the tension
wire
• Tension wire brought through
a drill hole in the ulna.
• Both sides of the tension wire
tightened to ensure even
compression

Figure from: Rockwood and Green’s, 4th

ed.
 INTRAMEDULLARY NAILS
 Relative stability
achieved via
intramedullary
splint
 Allows axial
loading of fracture
 Healing primarily
by secondary bone
healing
 Intramedullary Fixation
 Generally utilizes closed or minimally open
reduction techniques

 Greater preservation of soft tissues as compared

to ORIF

 IM reaming has been shown to stimulate

fracture healing

 Expanded indications i.e. Reamed IM nail is

acceptable in many open fractures
 Intramedullary Fixation
 Rotational and axial stability
provided by interlocking
screws

 Reduction can be technically

difficult in segmental,
comminuted fractures

 Fractures in close proximity

to metaphyseal flare may be
difficult to control
• Open segmental
tibia fracture treated
with a reamed,
locked IM Nail.

• Note the use of

multiple proximal
interlocks where
angulatory control is
more difficult to
maintain due to the
metaphyseal
flare.
• Subtroch fracture
treated with closed
IM Nail.

• The goal here is to

restore alignment
and rotation, not to
achieve anatomic
reduction.

• Without extensive
exposure this
fracture formed
abundant callous Valgus is restored...
by 6 weeks.
 OPEN FRACTURES
 Definition – Fracture with associated wound
communicating with the # site

 Classification – Gustillo Anderson - I, II, III

 Main concerns - Infection

- Soft tissue coverage
 Mx PRINCIPLES
 Early antibiotic initiation

 Thorough wound debridement and washout

 Temporary fixation with EX-Fix to allow access to

soft tissues

 Aim for early wound closure

 Rx as closed # once wound clean & closure

attained
PRIORITIES IN POLYTRAUMA
 Polytrauma Patient
Definition - Injury Severity
Score >18
Generally have

-Hemodynamic
instability
- Risk of Coagulopathy
- Closed head injury
- Pulmonary injury
- Abdominal injury
 Injury Severity Score
 Def.: scale of anatomic injury

 ISS is the sum of the squares of the three highest

AIS categories

 AIS (Abbreviated Injury Scale) – looks at five

categories: general, head and neck, chest,
abdominal, and extremities

 Maximum ISS is 75
Abb’ Injury Severity Scores
 Multidisciplinary Trauma Team

 Trauma Surgeon TEAM  Interventional radiology

LEADER  Intensivist
 Anesthesia  Hospital Staff-Nursing,
 Musculoskeletal PT, OT, Speech, Admin.
traumatologist  Legal/Security
 Neurosurgeon  Social work
 Vascular/CT surgeon  Ministry
 Urology, Gynecology
 Trauma Mortality
 Early phase - Immediate death
 Severe brain injury, disruption of great vessels,
cardiac disruption

 Second phase - Minutes to hours

 Subdural, epidural hematomas, hemopneumothoraces,
severe abdominal injuries, multiple extremity injuries
(bleeding)

 Third phase-delayed
 multisystem organ failure
 sepsis
 FRACTURES IN MULTIPLE INJURY
PT
 Early fixation has advantage of:
- Less mortality
- Allows for care of other injuries

 Definitive # fixation at time of surgery for other

injuries the best.

 Damage control surgery (Ex Fix) where

definitive Sx not possible
 SUMMARY
 Thorough evaluation to ID all injuries
 Team approach
 Head Injury, Thoracic Injury & Abdodominal
Injuries take precedence
 Early fixation of fractures beneficial
 Damage Control Surgery
QUESTIONS ? ? ?