Long Bone Fracture Treatment Principles

Dr Rashid Mayoka
Birnin Kebbi, Nigeria
5.2.2018
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Learning Outcomes

 Discuss the initial assessment and

management of a patient presenting with a
fracture.

 Describe the basic principles of fracture

management.

 Identify the fractures that need non-operative

treatment.

 Monitor healing and identify complications.

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Principles of Long Bone Fx Mx

1. Reduction
̶ Fracture reduction to restore
anatomical relationships
2. Fixation
̶ Fracture fixation providing
absolute or relative stability as
the “personality” of fracture,
patient and injury requires.
3. Blood supply
̶ Preservation of blood supply to
soft tissues and bone
4. Mobilization
̶ Early and safe mobilization of the
injured part and the patient as a
whole.
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 General principles
 Limb length shortening up  Spiral fracture healing is
to 1 to 2 cm can be swift and uneventful
tolerated. although holding
reduction without fixation
 Minimal angular may be difficult.
deformities up to 10
degrees A/P bowing in
lower extremities.  Wedge fractures union
may take a long time.
 Up to 5 degrees
Valgus/varus deformity  Transverse fractures
may subject the joint to
abnormal forces and lead usually displaced
to post traumatic O.A.

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 Upper limb
 Humerus – tolerates more deformity.
̶ > 15 degrees in <6yrs
̶ > 10 degrees in 6-12yrs
̶ Any slight angulation in >12yrs maybe difficulty to remodel
̶ In adults most surgeons opt for ORIF (plates & screws).
 Radius/ulna -require anatomic reduction for normal
limb function.
̶ Anatomical reduction is extremely important in adults to
maintain reasonable function.
̶ Closed reduction is usually successful in children because of
thick periosteum.
̶ Remodels well, unless there is rotational or angular
deformity.
 Physiotherapy and occupational therapy are crucial
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Upper limbs

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Lower limbs
 The normal mechanical
axis of the limb should be
 Weight bearing and return
restored.
to normal ambulation is
important.  This requires union
without shortening,
 Aim is to restore joints ROM
angulation and rotation.
affected by stiffness due to
treatment methods.
 Avoid excessive limb
shortening, angulation and
rotational deformity
 Consider patient’s
profession,

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Lower limbs

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 Operative vs non-operative
ABSOLUTE
1. Saving life e.g. polytrauma
patients.
2. Saving limb e.g. arterial
injury.
̶ Compartment syndrome
̶ Open fractures
̶ Neurovascular loss.
̶ Joint involvement.
RELATIVE
Failure of non operative
treatment, femur has more
complications from non
operative treatment.
Tibia easy to manipulate.
RELATIVE
Humeral fractures tolerate
significant degrees of
malunion, surgical fixation
indicated in special cases.
Forearm difficult to reduce
and hold anatomically non
operatively, surgery is usually
indicated.
Early mobilization of pts
especially elderly, early return
to work, shorter stay in
hospital and cost.
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4 indications of operative mx

I. Difficulty fractures
̶ Intra-articular Fx
̶ Both midshaft (diaphysis) forearm Fx

II. Pathological fractures

III. Multiple long bone fractures

IV. Patient preference

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Long Bone Fracture Reduction

Anatomical reduction

of every diaphyseal fracture fragment

is not necessary for normal limb function

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Principles of # management

 Initial & definitive treatment, involves

splinting and resuscitation.

 Period of Immobilization

 Assessment of Union

 Rehabilitation

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Initial Mx

 ATLS (save life then save a limb)

 Resuscitation
 Splintage.
̶ Commercial and makeshift
 Advantages
̶ Pain relief
̶ No further damage
̶ Avoid fat embolism
̶ Transportation
̶ Reduces hemorrhage
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4 Principles of # Treatment

1. Reduction - restore alignment rotation and

length.
2. Fixation/immobilisation
1 Traction
2 External Splinting
3 External skeletal fixator
4 Internal Fixation
3. Preserve blood supply
4. Rehabilitation (early and safe)
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Reduction

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Common Non operative Tx methods

 POP or Fiber glass  Only immobilise what

cast/splint/Slab is necessary
̶ Pressure point padding

 Skin and skeletal

traction
̶ Perkin's exercises

 Braces/splints

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Principle of immobilization

 Immobilise a joint above

and a joint below for
long bones #s.

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REMOVAL OF IMMOBILISATION

 Removal of POP or Traction ~

 ~ average Healing Time of a Fracture

 children adults
 Upper Limb 3 6 12
 Lower Limb 6 12 24

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Assessment of union

 Clinical Assessment
̶ Duration of immobilisation.
̶ Less pain.
̶ Moving limb as a strut.
̶ Palpable mass (callus).
̶ Partial weight bearing.
 Radiological Assessment
̶ Appearance of hard callus.
̶ Continuity of medullary canal and trabeculations
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Rehabilitation

 Starts from day one

 Patient is encouraged to move

 Avoid joint stiffness

 As much as the fracture permits and the pain

allows
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Rehabilitation

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Take Home message

 Assess the patient:

̶ i. Life threatening injuries (save life)
̶ ii. Limb threatening injuries (then save a
limb)

 Treat the fracture:

̶ “Bone will heal anyhow somehow. Help it heal in
correct position and do no harm”
̶ i. Pain control
̶ ii. Reduction
̶ iii.Immobilization
̶ iv. Rehabilitation
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Take home Msg

1. Reduction
̶ Fracture reduction to restore
anatomical relationships
2. Fixation
̶ Fracture fixation providing
absolute or relative stability as
the “personality” of fracture,
patient and injury requires.
3. Blood supply
̶ Preservation of blood supply to
soft tissues and bone
4. Mobilization
̶ Early and safe mobilization of the
injured part and the patient as a
whole.
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Thank You

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