PRINCIPLE OF

MANAGEMENT
By Dr Mahadhir Akmal
Orthopedic Department,
Hospital Seberang Jaya
 Objectives
• Definition
• Closed fracture
• Open fracture
• Bone healing
• Principles of management
• Complication
 Definitions
• Fracture is a break in the structural continuity
of bone.
• Causes:
I. Injury
II. Repetitive stress
III. Abnormal weakening of the bone (patholohgical
fracture)
 Classification
• Open fracture
- When fracture site communicates with external
environment
- For long bones based on
Gustillo’s Anderson classification

• Closed fracture
- Broken bone does not break the skin
Bone healing
 Bone healing
1)Tissue destruction and hematoma formation
2)Inflammation and cellular proliferation
3)Callus formation
4)Consolidation
5)Remodelling
 Bone healing
1)Tissue destruction and hematoma formation
• Vessel are torn
• Bone at the fracture surface deprived of blood supply

2)Inflammation and cellular proliferation

– Acute inflammatory reaction within 8 hours
– Initiation of proliferation and differentiation of
mesenchymal stem cells
– The clotted hematoma slowly absorbed and fine new
capillaries grow into the area
3) Callus formation
– Differentiating stem cells provide chondrogenic and osteogenic cell populations
– Start forming bone and also cartilage
– Osteoclast from the new blood vessel begin to mop up dead bone
– Immature fibre bone (woven bone) becomes densely mineralised
– Fractures unite at about 4 weeks after injury

4) Consolidation
– Woven bone transformed into lamellar bone
– Osteoblast fill in the remaining gaps between the fragments with new bone
– May takes several month

5) Remodelling
– Over periods of month or years, bone will be reshaped by a continuous process of bone
resorption and formation
PRINCIPLE OF
MANAGEMENT
 TREATMENT OF FRACTURES
CONSISTS OF:

• To improve the position of the

Manipulation fragments

• To hold them together until they

Splintage unite; meanwhile, joint movement
and function must be preserved
 Fracture healing is promoted by muscle
activity and bone loading, so exercise and
early weight- bearing are encouraged

• 3 simple injunctions:
REDUCE

HOLD EXERCISE
 CLOSED FRACTURES
Reduction Hold Exercise

• Manipulation • Sustained • Prevention of

• Mechanical traction oedema
traction (Traction by • Active exercise
• Open operation gravity, • Assisted
Balanced movement
traction and • Functional
Fixed traction) activity
• Cast splintage
• Functional
bracing
• Internal fixation
• External fixation
 1/ REDUCTION
Aim:
• Adequate apposition
• Normal alignment of bone fragments

SITUATION WHEN REDUCTION Manipulation

IS UNNECESSARY
when
when
displacement
reduction is
unlikely to
Method
when there is
little or no
does not
matter (e.g in
succeed (e.g
with
of
displacement some
fractures of
compression
fractures of Open
reduction Mechanical
clavicle)
vertebrae) operation traction
 REDUCTION
I/ Manipulation
• Suitable for all minimally displaced #, # in children and for
fractures likely to be stable after reduction
• Methods :
Under anaesthesia and muscle relaxation

Distal part of the limb is pulled in the line of bone

As fragments disengage, they are repositioned

Alignment is adjusted in each plane

 CLOSED
REDUCTION
(a) Traction and counter- traction in the line of bone (b) Manipulation to
disimpact the fragments (c) Continued manipulation to press the distal
fragments into reduced position
 REDUCTION
II/ Mechanical Traction
• Some fractures difficult to reduce
by manipulation due to powerful
muscle pull (eg: fracture of femoral
shaft)
• But they can be reduced by
sustained mechanical traction,
which also serves to hold the
fracture until it starts to unite
 REDUCTION
III/ Open Reduction
INDICATIONS:

Failed closed reduction

Large articular fragments that need accurate positioning

Avulsion fractures- fragments are held apart by muscle

pull

Operation is needed for associated injuries (e.g arterial

damage)

Fracture will anyhow need internal fixation to hold it

 2/ HOLD
OBJECTIVES:

Restrict Aim:
movement • Splint fracture, not
Prevent • Alleviate pain entire limb
displacement • Promote soft tissue
healing
• Allow free
movement of
unaffected parts
 HOLD
By gravity

1.Sustained Balanced traction

traction
Fixed traction

5. External 2. Cast
fixation splintage
Available
methods
of holding
reduction

4. Internal 3.Functiona
fixation l bracing
 HOLD
I/ SUSTAINED TRACTION
• Limb distal to fracture exert continuous pull in
the long axis of bone

• i.e spiral fracture of long bone shaft (muscle

contraction displacement)

• Advantage; patient can move joints and exercise

muscles

• Disadvantage; patient at bed for long time

thromboembolism, respiratory problems and
general weakness
HOLD traction counter-traction

TRACTION BY GRAVITY BALANCED TRACTION FIXED TRACTION

• e.g # of humerus Skin traction • Useful when patient
• Weight of arm supplies • Adhesive strapping kept need to be transported
traction in place by bandages
• Wrist sling supports • Sustain a pull of <10% of • Limb held in Thomas’s
forearm body weight (not splint
• Sleeve cast/brace to >4/5kg) • Traction tapes tied to
upper part of arm distal end of splint
reduce movement at # Skeletal traction • Proximal padded ring of
site • Stiff wire/pin insert splints abuts firmly
through bone distal to # against pelvis
• Sustain a pull of 10% of
body weight
• Limb supported for
comfort and prevent
sagging at # site
- Thomas’s splint
- Braun’s frame)
 Methods of traction

(a) Traction by gravity (b-d) Skin traction- b(fixed) c (balanced) d (Russell traction)
(e) Skeletal traction with a splint and a knee flexion piece
 HOLD
SUSTAINED TRACTION
SKIN TRACTION SKELETAL TRACTION
 COMPLICATIONS
• Circulatory embarrassment
- Traction tapes and circular bandages may constrict the
circulation
- Gallows traction  child less than 12kg
• Nerve injury
- May predisposed to perineal nerve injury  drop foot
- Should prevent external rotation during traction
• Pin site infection
 HOLD
II/ CAST SPLINTAGE
• Plaster of Paris (POP)
• Distal limb # & # in children
• Advantages : safe, go home sooner
• Disadvantage: joints immobile
(MOVEMENT) stiffenminimized by :
- delayed splintage (use traction until
regain movement before POP)
- conventional cast  functional
brace when limb can be held w/o
much discomfort
PLASTER TECHNIQUE
 HOLD
CAST SPLINTAGE
Complications
TIGHT CAST PRESSURE SORES
• Cast maybe too tightly applied/limb • Cast press upon skin over bony
swelling prominence
• Diffuse pain • Localized pain over pressure spot
• Signs of vascular compression • Immediate inspection through a
• Elevate limb  pain not subsided  window in cast
split the cast • Prevented  padding all bony
prominence before applying casts

SKIN ABRASION LOOSE CAST

• Complications of removing plasters • swelling subsidedcast may
(use of electric saw) loosereplaced
 HOLD
III/ FUNCTIONAL BRACING
• Objective : prevent joint stiffness +allow
joint movement +permit # splintage and
loading
• Cast segments applied over shafts of
bones leave joint free OR cast
segments above and below joint
connected by metal/plastic hinges
• Femur/tibial fracture
• After # begin to unite (after 3-6weeks of
traction/ restrictive splintage
• Advantages : hold well, move joints, safe,
normal speed recovery
 HOLD

IV/ INTERNAL FIXATION

INDICATIONS ADVANTAGES DISADVANTAGES

• # cannot be • hold well • unsafe full

reduced except • early movement weight-bearing
operation • early leaving • sepsis if infection
• Unstable # re- hospital supervenes
displace after (SAFETY)
reduction
• Poor and slow
unite #
• Pathological #
• Multiple #
• # in patient with
severe nursing
difficulties
 HOLD
INTERNAL FIXATION
TYPES OF INTERNAL FIXATION
SCREWS WIRES PLATES AND INTRAMEDULLARY
SCREWS NAILS
Interfragmentary Kirschner wires Diaphyseal Long bones
screws (lag screws) hold fracture fractures of Long rod insert into
fix small fragments fragment, radius and ulna medullary canal-
onto main bone (percutaneously ) splint
Metaphyseal Locking screws-resist
In quick healing fractures of long rotational forces
bone
 HOLD
INTERNAL FIXATION
Complications
INFECTION NON-UNION
• Iatrogenic ;quality of patient’s tissue • Causes :
and open operation  chronic - Excessive soft tissue
osteomyelitis stripping
• No rapid IV antibiotic  replaced - Damage blood supply
implant with external fixation - Rigid fixation with a gap
between fragments
- Implant breakage

IMPLANT FAILURE REFRACTURE

• Stresses to metal subjects unless
some union of fracture has occurred
• Eg: patient with fracture of tibia
internally fixed should walk with
crutches and stay away from PWBA
for 6/52 until callus is seen in xray
• Not to remove metal implants too
soon (bone maybe refracture)
Minimum: in a year
18/24 months=safer
 HOLD
V/ EXTERNAL FIXATION
• bone is transfixed above and below fracture with
screws/pins/tensioned wires  clamp to a frame/
connected to each other by rigid bar
• long bones and pelvis Fracture
with severe
soft tissue
damage
(wound left
open)

Infected Soft tissue

fracture swollen

INDICATIONS

Severe
Ununited
multiple
fracture
injuries
 HOLD
EXTERNAL FIXATION
Complications
DAMAGE TO SOFT TISSUE OVER-DISTRACTION
STRUCTURES

• Injure nerve or vessels • No contact between fragments 

• Tether ligament delay or prevent union

PIN-TRACK INFECTION

• Immediate antibiotics if occurs

 3/ exercise
Preserve
joint
movement Restore
Reduce
muscle
oedema
power

Guide the
Restore OBJECTIVES
patient back
function to normal
activity
 exercise
Prevention of Active Assisted Functional
Oedema Exercises Movement Activity
• Elevation • reduce • Forced • Teach the
and active oedema movements patient how
exercises • stimulate should never to do
• Patient circulation be permitted everyday
encouraged • prevents soft • Gentle tasks such as
to use the tissue assistance walking,
limb and to adhesion during active getting in
keep moving • promote exercises and out of
the joints fracture • Eg continuos bed, dressing
that are free healing passive and handling
• Oedema may motion eating
cause tissue utensils
tension,
blistering
and joint
stiffness
 OPEN FRACTURES

Initial Management

Principle of Treatment
• Wound debridement
• Antibiotic Prophylaxis
• Fracture stabilization
• Early definitive wound
cover
 INITIAL MANAGEMENT
• Aim :
- Reduce risk of further contamination and wound
desiccation
- Splint
- Sterile dressing

• General assessment (multiple injuries & severe shock)

• Tetanus toxoid (immunised) /
human antiserum (not immunised)
• Given antibiotic (
amoxicillin/cefuroxime/clindamycin)
• Wound inspection
Site, size, tidy/ragged, clean/dirty, communicate with fracture, soft tissues,
circulation, nerve
 Wound
debridement

PRINCIPLE OF
Wound Antibiotic
closure MANAGEMEN prophylaxis
T

Stabilization
of fracture
 sterility and antibiotic cover

• In most cases:
- amoxicillin/cefuroxime/clindamycin
- At the time of debridement, above + Gentamicin is
added (to cover gram-negative & gram positive)

• Gustillo’s grade I: antibiotic prophylaxis need not be

more than 24 hours
• Gustillo’s grade II and III
- Gentamicin and vancomycin are given at the time of
wound cover
- Effective against MRSA and Pseudomonas
Total antibiotic should not be greater than 72 hours
 DEBRIDEMENT AND WOUND
EXCISION

Dressing with sterile Surrounding skin Wound irrigated with

pad cleaned and shaved warm normal saline

Ragged
margins/debris/dead
Washed again with
tissue excised to
warm NS 6-12L
leave healthy skin
edge

Dead tissue-purplish, no contract, no bleed

when cut, mushy in late feature
WOUND CLOSURE
Uncontaminate Other wounds-
d type I and II left open

debridement, Packed with

wound excision  moist, sterile
sutured without gauze/ adding
tension gentamicin beads/
VAC

Inspect after 24-48

hours

Sutured or skin
grafted (delayed
primary closure)
 STABILIZATION OF
FRACTURES
• Reduce infection + assist soft tissue recovery
Method of
fixation depends Method of stabilization
on: • Cast splintage
• The degree of • Intramedullary nailing
contamination • Locked nailing
• The length of • External fixation
time injury to • Plates and screws
operation (metaphyseal/articular
• Amount of soft fracture/smaller tubular
tissue damages bones fracture)
 post operation:
• Elevate and monitor limb circulation
• Continue antibiotic cover
• Swab sample
• Inspect wound at 2-3 days (open wound)
• Teamwork between plastic surgeon and
orthopaedic (delay primary closure/large
extent on the type of soft tissue covered)
 Complication
Early complications
• Visceral injury
• Vascular injury
• Nerve injury
• Compartment syndrome
• Hemarthrosis
• Infection
• Gas gangrene
• Late blisters
• Plaster and pressure sores
Late complications
• Delayed union
• Non-union
• Malunion
• Avascular necrosis
• Growth disturbance
• Bed sores
• Myositis ossificans
• Muscles contracture
• Joint stiffness
 TAKE HOME MESSAGE
• Management of fractures
- ABC’s, primary survey, secondary survey (ATLS protocol)- rule out other fractures/ injuries/ open
fractures
- AMPLE HISTORY (Allergies, Medications, PMH, Last meal, events surrounding injury)
- Analgesia
- Imaging
- Splint Extremity

1/ Obtain the reduction

- Close reduction apply traction in long axis of limb
- Open reduction (Indication: “NO CAST”- Non Union, Open Fracture, Neurovascular Compromise,
Intra- Articular fracture, Salter Harris 3,4,5, PolyTrauma)
2/ Maintain reduction (Ext stabilization, Int stabilization), post reduction imaging and follow up for
bone healing
3/ Rehabilitate: To regain function and avoid joint stiffness

OPEN FRACTURES: (Swab wound for culture, irrigation, debridement: removal of foreign materials,
devitalised tissue, old bloods, cover wound with sterile dressings, tetanus status, IV antibiotics,
splint fracture, NBM and prepare for operative irrigation and WD within 24hours to dec risk of
infections)
GUSTILO- ANDERSON Classification of Open Fractures
 REFERENCES
• Apley’s Sytem of Orthopaedics and Fractures