Reduction and stabilisation of fractures

Reduction and stabilisation of fractures

Reduction and stabilisation of fractures

PRINCIPLES OF FRACTURE TREATMENT


General Treatment of injured patients

  • First aid at the scene of accident
  • Transport to a hospital
  • Resuscitation : Airway, Breathing & Circulation

Specific treatment of fractures

  • Reduce
  • Immobilise
  • Rehabilitate

REDUCE

Can be closed or open reduction.

Closed reduction or manipulation under anaesthesia for 

Minimally displaced fractures.
Fractures in children.
Fractures that are stable after reduction.

Open reduction for 

  • Failure of closed reduction.
  • Displaced intra articular fractures.
  • Unstable fractures.
  • Traction fractures.

IMMOBILISE (HOLD REDUCTION )

Continuous traction is applied to the limb distal to the fracture to exert continuous pull in the long axis of the bone.

 

  • by skin traction-two adhesive strips are stuck on to either side of the leg & weights are attatched to these strips by a rope (for femoral shaft fractures in children).
  • by skeletal traction-through a pin placed in the tibia for femoral shaft fractures in adults.This can be fixed or balanced.
  • by gravity-a hanging cast for displaced fractures of the humeral shaft.

Cast splintage

  • Can be plaster of Paris or synthetic casts.
  • A back slab is usually used initially followed by a complete plaster when the swelling subsides.
  • Adequate padding must be used over bony prominences.
  • The joint above and below the fractured bone must be immobilised.
  • The limb must be elevated & circulation distally should be checked.

Internal fixation

Indications

  • failure of closed reduction
  • unstable fractures
  • pathological fractures
  • fractures that unite poorly ( femoral neck)
  • multiple fractures

Methods

  • Screws and plates
  • Steel wires
  • Intra medullary nails.

 
External Fixation

Transfixing screws are passed through the bone and are attached to an external frame.

Types      Tubular ( A O ), Ring (ILIZAROV)

Indications

  • Fractures associated with severe soft tissue injury.
  • Severe multiple injuries (associated with chest injury).
  • Pelvic fractures.
  • Infected fractures.

EXERCISE: (Rehabilitation)

  • Prevent oedema – elevate limb.
  • Upper limbs – sling.
  • Lower limbs – elevate on pillows/chair.
  • Active exercise.
  • Helps circulation.
  • Decreases oedema.
  • Helps to avoid joint stiffness.
  • Gentle assisted movements are also helpful ( CPM ).
  • Gradual return to functional activity.

OPEN FRACTURES
Grade I (Gustilo & Anderson)

  • Small, clean wound less than 2 cm long.
  • No crushing or communition.

Grade II

  • Wound 2cm to 5cm long. Slight contamination
  • Moderate crushing and comminution.

Grade III

  • Wound greater than 5cm.
  • Marked damage to soft tissues and considerble contamination and comminution of fracture & periosteal stripping).
  • As in a but bone cannot be adequately covered by soft tissue.
  • Associated nerve and vascular injury.

EARLY MANAGEMENT: ( Emergency Room )

  • Dressing over the wound.
  • IV antibiotics
  • Tetanus prophylaxis
  • Temporary splinting (POP Slab )

Debridement

  • Irrigation with at least 3 litres of saline (6-10 litres recommended)
  • No tourniquet.

Skin:

Excise 2mm thickness at wound edges – also any skin that is necrotic.
DO NOT SUTURE THE WOUND

Muscle:     4 ‘c’s –

  • Colour
  • Consistency
  • Contractility
  • Capacity to bleed.

Nerves:

Leave cut nerve undisturbed.

Tendons:

Leave cut ends alone – only suture if totally clean.

Bone:

Only remove small and totally detached fragment.Clean and retain large fragments & those with some soft-tissue attatchment.

Stabilising the fracture

Safest method is external fixation. Intra – medullary nailing can be used for the tibia and femur.(If the wound is not very contaminated and a thorough debridement has been done)

Methods of internal fixation 
1.Internal methods 
1.PLATE & SCREWS
 
2.INTRA MEDULLARY NAIL
 

 

3.PROSTHETIC REPLACEMENT
 

 

2. External methods  
 
UNIVERSAL AO FIXATOR
 

 

 
 

 Complications 
DELAYED UNION – 12 WEEKS
MALUNION
 
 NON UNION
AVASCULAR NECROSIS
 

 


S.P.Suresh FRCS (Gen), FRCS (Orth).
Consultant Orthopaedic Surgeon
Email: [email protected]

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