Surgery: Principles of Fracture Management PDF

PRINCIPLES OF MANAGEMENT OF FRACTURES OUTLINE INTRODUCTION CLASSIFICATION OF FRACTURES PRINCIPLES OF MANAGEMENT OF FRACTURES RESUSCITATION REDUCTION RETENTION SOFT TISSUE IMMOBILIZATION REHABILITATION CONCLUSION REFERENCES INTRODUCTION A Fracture is a b...

PRINCIPLES OF MANAGEMENT OF FRACTURES OUTLINE INTRODUCTION CLASSIFICATION OF FRACTURES PRINCIPLES OF MANAGEMENT OF FRACTURES RESUSCITATION REDUCTION RETENTION SOFT TISSUE IMMOBILIZATION REHABILITATION CONCLUSION REFERENCES INTRODUCTION A Fracture is a break in the continuity of a bone. It is: 1. Closed (Simple) when there is no laceration of the skin overlying it. 2. Open (compound) when there is a laceration of the skin which communicates with it thereby allowing the fracture to communicate with the outside environment. A compound fracrure is said to be 'compound from within' when the laceration of lhe skin is caused by a fragmemt of the broken bone and 'compound from without ' when the laceration is caused by the force which gave rise to the fracture. 3. A pathological fracture is one which occurs in an abnormal or diseased bone. The force required to produce the fracture is minimal or trivial, The disease may be localized (e.g. cyst or metastasis) or generalized (e.g. osieoporosis or rickets) CLASSIFICATION Based on several ways: Extent Location Morphology Mechanism Associated soft tissue injuries Based on Extent. Complete: fracture extends 360 ° of bone circumference (all around). Incomplete: seen almost only in children: Greensick Buckle fracture Based on the Location. Name of bone Side Diaphysis, metaphysis or epiphysis Long bones (diaphysis): divide them in thirds (proximal, middle or distal third) Morphology: Transverse: is one in which the bone is broken almost transversely across and is caused by either an indirect bending force or a direct tapping force. Morphology: Oblique: is oblique in outline and also results from bending indirect violence. The bone fragments tend to be displaced as a result of the muscles even after reduction. Morphology: Spiral: is one in which the fracture is spiral in pattern. It is caused by twisting force from indirect violence. Morphology: Comminuted fracture: is one in which there are more than two fragments at the site of a fracture. lt is often caused by direct violence or crushing injury. Segmental fracture: is one in which the affected long bone is broken at two or more distlnct levels. Mechanism: High energy vs. low energy. Multiple injuries vs. isolated injury. Pathological fracture: normal load in the presence of a weakened bone (tumor, osteoporosis, infection) Stress fracture: normal bone subjected to repeated load (military recruits). Associated soft tissue injuries: Close fracture: skin integrity is maintained. Open fracture: fracture hematoma is exposed to external environment. PRINCIPLES OF MANAGEMENT OF FRACTURES The goals of treatment of fractures are: 1. Reduction of the fracture to correct any deformity and restore normal anatomy. 2. Adequate immobilization of the fracture to maintain reduction and the alignment of the bone during healing and also to promote healing. Adequate immobilization must be maintained until union of the bone is sound. 3. Maintenance of joint mobility by active movement of the joints not immobilized. 4. Maintenance of muscle tone by exercising the muscle of the affected limb during immobilization.  These are the principles of management 1. RESUSCITATE 2. REDUCTION 3. RETENTION 4. SOFT TISSUE MANAGEMENT 5. REHABILITATION RESUSCITATION RESUSCITATION using the ATLS principle (PRIMARY AND SECONDARY SURVEY) Airway maintenance and cervical spine control Breathing Circulation Disabilities: brief neurological assessment Exposure Splintage to prevent further damage by movement of fragments Antibiotics Analgesics Antitetanus (Subcut 1500IU ATS) REDUCTION It is achieved by: 1. Closed manipulation whenever possible 2. Open reduction if closed manipulation fails or is not likely to succeed. Closed Reduction A. Closed manipulation Under general, local or regional anaesthesia, the fractured fragments are manipulated with a force opposite in direction to the one that produced the fracture in order to restore the normal anatomy. OPEN REDUCTION Open reduction implies the opening of skin or mucusa to visualise the fracture and inspect the adequacy of reduction with our eyes. INDICATIONS 1. Failure of closed reduction. This may be due to: (i) interposition of some tissues between the fractured fragments. (ii) displacement of the fracture fragments by contraction of the muscles. (iii) displacement of inaccessible intra-articular fragments e.g. fractured head of radius. (iv) late unreduced fracture. 2. Failure in maintaining reduction after closed manipulation in certain types of fractures e.g. oblique or spiral fracture of the tibia, transverse fracture of the patella. 3. Fractures that cannot be reduced by the closed method e.g. fractures around joints. 4. Difficulty in getting hold of a short fractured fragment e.g. fracture dislocation of the shoulder. 5. Associated arterial injury. RETENTION BY IMMOBILIZATION lmmobilization after reduction is by (a) splints (b) traction. (c) Fixation a) The splints are usually made of plaster of Paris (POP) but may be of wood, metal, external fixators or light weight casting material such as Scorch cast or Fibreglass. b) Traction: Continuous traction on a limb also immobilises the fracture and maintains the alignment of the bony fragments. It is used in lower limb fractures. The leg is put in a suitable frame. The traction may be (i) skin traction or (ii) skeletal traction. i) Skin traction: A non-elastic adhesive plaster is attached to the skin and a weight applied to a cord leading from this adhesive plaster. Skin traction cannot be used when weights more than 5kg are needed for traction as this tends to rip off the adhesive plaster. ii) Skeletal traction: A metal wire or pin e.g. Steinman's pin is inserted into the bone below the fracture and attached to a weight through a cord which pulls the bone to correct the deformity. lnternal fixation Different types of materials are available for the intenal fixation of a fracture ie. wire, screws, pins, plates and intramedullary nail. Stable bone fixation is the aim and makes external immobilization often unnecessary. These materials are made of stainless steel, titanium or vitallium which is cobalt-chromium- molybdenum alloy.  External skeletal fixation The fracture is fixed externally with a special external metal frame. Pins are inserted into the bone above and below the fracture and then fixed into the external metal frame. Fixation is rigid. This method is indicated in severe open fractures especially of the tibia, femur, humerus, radius and ulna if there is marked soft tissue damage with skin loss which may require frequent dressing or skin grafttng. It allows ready access to the wound. It is also indicated in closed fractures in patients with multiple trauma, head injury or burns, in fractures requiring distraction (e.g. bone loss) and in non-union. The external metal frame may be single e.g. the Orthofix or Oxford External Fixation, or double e.g. Hoffman's Fixator. Some external fixators have modifications that allow them to be used for limb lengthening procedures in patients with bone loss and shortening e.g. Ilizarof fixator  There are two types of the external fixators. We have the circular and the linear. Components of the linear ex-fix include; Pins(schantz screw, denham’s pin and steinman’s pin), clamps and connecting rod Components of circular ex-fix; Pins, wires, clamps and frame The prime disadvantage of an external fixator is the ‘pin sites’. These pin sites require care as they may become infected or tether soft tissues, thereby interfering with function. REHABILITATION The main aim of treatment is to return the patient to a similar level of premorbid function as quickly as possible. It is important to move the affected joints and the joints in close proximity to the fracture (e.g. elbow and shoulder exercise while in a cast for a distal radial fracture), limiting global stifness and wasting of the muscles on that limb. COMPLICATION EARLY LATE Infection Non-union Compartment syndrome Mal-union Haemorrhage Shortening Osteomyelitis Hypovolaemic shock Osteoarthritis Septicaemia Volkman’s ischaemic Fat embolism contracture Crush syndrome DVT&PE Disuse atrophy of affected limb CONCLUSION Fracture is the one of the common orthopaedic conditions and as such, appropriate and effective measures should be taken to save life of patient, save the limb, save joint and restore function(as much can be restored). REFERENCES Baja’s priciple and Practice of Surgery 5th Edition Bailey and Love