Reduction and stabilisation of fractures
General Treatment of injured patients
- First aid at the scene of accident
- Transport to a hospital
- Resuscitation : Airway, Breathing & Circulation
Specific treatment of fractures
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.
- 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.
- failure of closed reduction
- unstable fractures
- pathological fractures
- fractures that unite poorly ( femoral neck)
- multiple fractures
- Screws and plates
- Steel wires
- Intra medullary nails.
Transfixing screws are passed through the bone and are attached to an external frame.
Types Tubular ( A O ), Ring (ILIZAROV)
- Fractures associated with severe soft tissue injury.
- Severe multiple injuries (associated with chest injury).
- Pelvic fractures.
- Infected fractures.
- 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.
- Small, clean wound less than 2 cm long.
- No crushing or communition.
- Wound 2cm to 5cm long. Slight contamination
- Moderate crushing and comminution.
- 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 )
- Irrigation with at least 3 litres of saline (6-10 litres recommended)
- No tourniquet.
Excise 2mm thickness at wound edges – also any skin that is necrotic.
DO NOT SUTURE THE WOUND
Muscle: 4 ‘c’s –
- Capacity to bleed.
Leave cut nerve undisturbed.
Leave cut ends alone – only suture if totally clean.
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)
Consultant Orthopaedic Surgeon
Email: [email protected]