Principles of fracture treatment.pdf

Principles of fracture treatment Prof Dr. Anwar Ebid INITIAL MANAGEMENT Before definitive treatment of a fracture is undertaken, attention must be directed to first aid treatment (Advanced Trauma Life Support (ATLS) principles), to the clinical assessment of the patient with special reference to the...

Principles of fracture treatment Prof Dr. Anwar Ebid INITIAL MANAGEMENT Before definitive treatment of a fracture is undertaken, attention must be directed to first aid treatment (Advanced Trauma Life Support (ATLS) principles), to the clinical assessment of the patient with special reference to the possibility of associated injuries or complications, and to resuscitation. A- First aid 1-Ensure that the airway is clear. 2-Control any external haemorrhage. 3-Cover any wound with a clean dressing. 4-Provide some form of immobilization for a fractured limb. 5-Make the patient comfortable while awaiting the arrival of the ambulance. B-Resuscitation Many patients with severe or multiple fractures, or fractures associated with other visceral injuries, are shocked on arrival at hospital. Time must be spent on resuscitation. Hemorrhagic shock can develop rapidly when there has been a rapid loss of a large volume of blood. 6- Traction is applied to the limb while it is being moved. 7- Special care is necessary in transport, patient with spinal cord or cauda equina 8- It is most important to avoid flexing the spine, because flexion may cause or increase vertebral displacement, jeopardizing the spinal cord. 9- In certain types of fracture, extension is also potentially dangerous to the cord. 10- The patient should be lifted bodily on to a firm surface, with care to avoid both flexion and extension. 11-If a cervical collar is available, it should be applied as a protection for the neck before moving the patient, without allowing either flexion or extension of the neck during its application. 12-Temporary immobilization for the long bones of the lower limb by bandaging the two limbs together so that the sound limb forms a splint for the injured one. In the upper limb, support may be provided by bandaging the arm to the chest or, in the case of the forearm, by improvising a sling. 13-Haemorrhage hardly need a tourniquet for its control. 14-All ordinary bleeding can be controlled adequately by firm bandaging over a pad. Only if profuse pulsatile (arterial) bleeding persists despite firm pressure over the wound, Pending its application, firm manual pressure over the main artery at the root of the limb may be applied to control the bleeding. 15- A note should be sent with the patient and If morphine or a similar drug is given at the scene of the accident on admission to hospital. Clinical Assessment It must be emphasized again that an immediate assessment of the whole patient is required to exclude injuries to other systems before examination of the skeletal injury. Examination of the limb should determine: 1-whether there is a wound communicating with the fracture 2-whether there is evidence of a vascular injury 3-whether there is evidence of a nerve injury 4-whether there is evidence of visceral injury. TREATMENT OF UNCOMPLICATED CLOSED FRACTURES The three fundamental principles of fracture treatment are: REDUCTION A- IMMOBILIZATION B- PRESERVATION OF FUNCTION C- A-REDUCTION Methods of reduction 123- By closed manipulation By mechanical traction with or without manipulation By open operation 1-Manipulative reduction Closed manipulation is the standard initial method of reducing most common fractures. It is usually carried out under general anesthesia, but local or regional anesthesia is sometimes appropriate. The technique is simply to grasp the fragments through the soft tissues, to disimpact them if necessary, and then to adjust them as nearly as possible to their correct position. 2-Reduction by mechanical traction When the contraction of large muscles exerts a strong displacing force, some mechanical aid may be necessary to draw the fragments out to the normal length of the bone. This particularly applies to fractures of the shaft of the femur, and to certain types of fracture or displacement of the cervical spine. Traction may be applied either by weights or by a screw device, and the aim may be to gain full reduction rapidly at one sitting with anesthesia, or to rely upon gradual reduction by prolonged traction without anesthesia 3-Operative reduction When an acceptable reduction cannot be obtained, or maintained, by these conservative methods, the fragments are reduced under direct vision at open operation. Open reduction may also be required for : 1- Fractures involving articular surfaces 2- Fracture is complicated by damage to a nerve or artery. B-IMMOBILIZATION Like reduction, this second great principle of fracture treatment must be qualified by the words 'if necessary’. Whereas some fractures must be splinted rigidly, many do not require immobilization to ensure union, and excessive immobilization is harmful in some INDICATIONS FOR IMMOBILISATION There are only three reasons for immobilizing a fracture: 1-To prevent displacement or angulations of the fragments 2-To relieve pain. 3-To prevent movement that might interfere with union Two examples of fractures that require immobilization [A] Fracture of the scaphoid bone; [B] fracture of the neck of the femur. 1-Prevention of displacement or angulations In fractures of the shafts of the major long bones, however, immobilization is usually necessary in order to maintain correct alignment. 2-Relief of pain Probably in about half of all the cases in which a fracture is immobilized the main reason for immobilization is to relieve pain 3-Prevention of movement As has been mentioned already, absolute immobility is not always essential to union of a fracture. There are three fractures that need immobilization to ensure their union namely, those of the scaphoid bone, the shaft of the ulna, and the neck of the femur. Examples of fractures that heal well without immobilization are those of the ribs, clavicle and scapula, and stable fractures of the pelvic ring. METHODS OF IMMOBILISATION Four methods can be used: 1234- Plaster of Paris cast or another external splint Continuous traction External fixation Internal fixation Immobilization by plaster, splint or brace For most fractures, the standard method of immobilization is by a plaster of Paris cast. Synthetic (plastic) splinting materials Are applied in much the same way as plaster bandages, usually with warm water. Since they are stronger weight for weight than plaster, fewer layers are required. Molding to the body contours is more difficult than with plaster bandages. Other external splints. Apart from plaster of Paris, Rarely, a halo-thoracic splint is used for an unstable fracture of the cervical spine. A layer of stockinet forms a comfortable lining which prevents the plaster from sticking to the hairs. An alternative is to use a single thickness of cellulose bandage. The hand is shown in a position of function, with slight dorsiflexion at the wrist and the thumb opposed. Thomas’s Splint Continuous skeletal traction through a tibial pin with balanced suspension, using a Thomas's splint and a Pearson knee flexion attachment. Cast bracing (functional bracing) A brace has come to be understood as a supportive device that allows continued function of the part. Cast bracing, or functional fracture bracing (to use a better term), is a technique in which a fractured long bone is supported externally by plaster of Paris or by a mouldable plastic material in such a way that function of the adjacent joints is preserved and use of the limb for its normal purposes can be resumed. Functional bracing is used mainly for fractures of the shaft of the femur or tibia. often about 5 or 6 weeks after the injury. Immobilization by sustained traction In some fractures—notably those of the shaft of the femur and certain fractures of the shaft of the tibia or of the distal shaft of the humerus ,it may be difficult or impossible to hold the fragments in proper position by a plaster or external splint alone. Sustained traction of this type is usually combined with some form of splintage to give support to the limb against angular deformity usually a Thomas's splint Immobilization by external fixation The term external fixation is referred to an external device such as a metal bar through the medium of pins inserted into the proximal and distal fragments of a long bone fracture. In its simplest form, external fixation may be provided by transfixing each fragment with a Steinmann pin and incorporating the protruding ends of the pins in a plaster of Paris splint. External fixation finds its main application in the management of open or infected fractures. The method has also gained some support as an alternative to internal fixation in the management of certain closed fractures of the long bones, particularly in the metaphyseal region. A more specialized configuration of external fixation is the circular or llizarov frame Diagram showing the principle of two types of external fixation. [A]Unilateral frame using threaded half-pins anchored to the external bar by clamps, [B] Circular (llizarov) frame with thinner transfixion wires attached to rings linked by adjustable rods. Immobilization by internal fixation Operative or internal fixation may be advised in the following circumstances: 2-As a method of choice in certain fractures, to secure immobilization of the fracture and to allow early mobility of the patient, e.g., in the elderly patient with trochanteric hip fracture 4-If it is impossible in a closed fracture to maintain an acceptable position by splintage alone. 1-To provide early control of limb fractures when conservative methods would interfere with the management of other severe injuries, for instance of the head, thorax or abdomen 3-When it has been necessary to operate upon a fracture to secure adequate reduction Design of a Bone FractureFixation Device Methods of internal fixation The following methods are currently in general use 1-Metal plate held by screws or locking plate (with screws fixed to the plate by threaded holes) 2-Intramedullary nail, with or without cross-screw fixation for locking 3-Dynamic compression screw-plate 4-Condylar screw-plate 5-Tension band wiring 6-Transfixion screws. Metals for internal fixation Metals used for internal fixation of fractures or for internal prostheses must be resistant to corrosion in the tissues: silver, iron, ordinary steel and nickelplated steel are all unsuitable. A special stainless steel containing chromium, nickel and molybdenum is widely used Methods of internal fixation The choice of method depends upon the site and pattern of the fracture. 1-Plate and screws. This method is applicable to long bones. Fixation by ordinary plates has the disadvantage that the bone fragments are not forcibly pressed into close contact 2-Locking plate. uses, particularly in the metaphyseal region. 3-Intramedullary nail. This technique is excellent for many fractures of the long bones, especially when the fracture is near the middle of the shaft. It is used regularly for fractures of the femur and tibia, and less commonly in the humerus. 4-Compression screw-plate. The compression screw-plate (dynamic hip screw (HDS) is a standard method of fixation for fractures of the neck of the femur and for trochanteric fractures. 5-Kirschner wire fixation. These thin flexible wires useful for the fixation of small bony fragments or for fractures of the small bones in the hand and foot. 6-Tension band wiring. This technique of fixation is most used in the patella and olecranon REHABILITATION Improved results in the treatment of fractures need much rehabilitation, perhaps the most important of the three great principles of fracture treatment. Reduction is often unnecessary; immobilization is often unnecessary; rehabilitation is always essential Rehabilitation should begin as soon as the fracture comes under definitive treatment. Its purpose is : First. To preserve function so far as possible while the fracture is uniting and Second. To restore function to normal when the fracture is united. This purpose is achieved not so much by any passive treatment as by encouraging patients to help themselves. The two essential methods of rehabilitation are 1-Active use and 2-Active exercises. Except in cases of minor injury, the patient should, ideally, be under the supervision of a physiotherapist throughout the whole duration of treatment 1-Active use This implies that the patient must continue to use the injured part as naturally as possible within the limitations imposed by necessary treatment. 2-Active exercises These comprise exercises for the muscles and joints. They should be encouraged from an early stage. While a limb is immobilized in a plaster or splint, exercises must be directed mainly to the preservation of muscle function by static contractions. The ability to contract a muscle without moving a joint is soon acquired under proper supervision. When restrictive splints are no longer required, exercises should be directed to mobilizing the joints and building up the power of the muscles. Finally, when the fracture is soundly united, treatment may be intensified movements. 3-Continuous passive motion (CPM) It is a machines that provide continuous To-and-Fro movement at a joint without any effort on the part of the patient. This technique of exercising joints passively has many applications: it is particularly valuable in situations where restriction of mobility tends to be hard to overcome, for Example; in the knee after fracture of the femoral shaft or after the operation of quadriceps plasty. Comment Neglect of proper rehabilitation may have serious consequences. An injured limb that is kept immobile and disused for a long period tends to suffer : Edema, wasting of the muscles and stiffness of the joints, with prolonged or even permanent impairment of function. TREATMENT OF OPEN FRACTURES Principles of treatment: The object is to clean the wound and, whenever necessary, to remove all dead and devitalized tissue and all extraneous material, leaving healthy well-vascularized tissues If the fracture is unstable and unsuitable for treatment by traction or by simple splintage alone, external fixation by pins inserted into the bone fragments and fixed to a rigid external bar is often the method of choice rather than internal fixation. Supplementary treatment in cases of open fracture 1-Antibiotics. 2-Prophylaxis against tetanus TREATMENT OF OPEN FRACTURES The principles of operation for open fracture. The aim is to clean away all dirt and foreign matter and to remove dead and devitalized muscle and small loose fragments of bone, leaving the wound surfaces clean and viable. [A] REMOVE Margin of necrotic tissue. [B] After excision, cleansing and removal of loose bone fragments. In most cases, and invariably when there is contamination, the wound is left open until the risk of infection has subsided. It may then be closed by delayed primary suture [C} or by skin grafting.