*** principles of treatment - Treat the patient, not only the fracture o General resuscitation is the first consideration

ABC - Treatment of the fracture o Manipulation Improve the position of the fragments o Splintage Hold the fragments together until they unite o Joint movement and function must be preserved o Exercise and early weight bearing Fracture healing is promoted by muscle activity and bone loading Main ob !s " #E$%&E, '()$, E*E#&+SE ***,racture -uartet. dual conflict o Encapsulates four important factors that influence the modern approach to fracture management - 'old vs/ Move o How to hold a fracture adequately and yet use the limb sufficiently Speed vs/ Safety o surgeon see s to resolve first conflict as rapidly as possible !eg with internal fi"ation#$ but without incurring unnecessary ris s ***&losed ,ractures #eduction - no undue delay in attending to the fracture o although general treatmtent and resuscitiaton must always ta e precedence o swelling of soft parts in first %& hrs ma es reduction increasingly difficult reduction unnecessary when. o There is little or no displacement o $isplacement does not matter Eg in some fractures of the clavicle o #eduction is unli0ely to succeed Eg with compression fractures of the vertebra - 1im of reduction o ade-uate apposition o normal alignment of the bone fragments greater contact surface area between fragments more li ely to heal gap delayed union or non'union fractures involving an articular surface should be reduced as near to perfection as possible( any irregulartiy will predispose to degenerative arthiritis - Methods of reduction

o o o

Manipulation Mechanical traction (pen operation

***Manipulation - &losed manipulation is suitable for 2/ 1ll minimally displaced fractures 3/ Most fractures in children 4/ ,ractures that are li0ely to be stable after reduction %nstable fractures are sometimes reduced 5closed! priort to mechanical fixation - Three fold maneuver. under anesthesia and muscle relaxation 2/ The distal part of the limb is pulled in the line of the bone 3/ The fragments are repositioned as they disengage a) By reversing the original direction of force if this can be deduced 4/ 1lignment is ad usted in each plane o Closed manipulation is *ost effective when the periosteum and muscles on one side of the fracture remain intact+ the soft , strap prevents over'reduction and stabili-es the fracture after it has been reduced ***Mechanical Traction - Some fractures 6eg of the femoral shaft7 are difficult to reduce by manipulation because of powerful muscle pull - They can often be reduced by sustained mechanical traction, which then serves also to hold the fracture until it starts to unite - +n some cases, rapid mechanical traction is applied, under anaesthesia and assisted by image intensification, prior to internal fixation ***(pen (peration (perative reduction under direct vision is indicated. 2/ 8hen closed reduction fails !either because of difficulty in controlling the fragments or because soft tissues are interposed between them# 3/ 8hen there is a large articular fragment that needs accurate positioning 4/ ,or avulsion fractures in which the fragments are held apart by muscle pull 9/ 8hen an operation is needed for associated in uries !eg arterial damage# :/ 8hen a fracture will anyhow need internal fixation to hold it ***'old - #estriction of movement o ;revention of displacement o 1lleviation of pain o ;romote soft-tissue healing o 1llow free movement of the unaffected parts Splint the fracture, not the entire limb - Methods of holding reduction. o Sustained traction

o o o o -

&ast splintage ,unctional bracing +nternal fixation External fixation

&losed vs/ operative methods o Closed methods are most suitable for fractures with intact soft tissues !provide a form of splintage# and are liable to fail if they are used for fractures with sever soft tissue damage .ther contraindications to non'operative methods are inherently unstable fractures multiple fractures$ fractures in confused or uncooperative patients

***Sustained traction Traction is applied to the limb distal to the fracture, so as to exert a continuous pull in the long axis of the bone +n most cases a counterforce will be needed ;articularly useful for spiral fractures of long-bone shafts, which are easily displaced by muscle contraction The <hold= is not perfect, but it is <safe= !as long as not e"cessive#$ the bone is gradually pulled out to length and meanwhile the patient can <move= the oints and exercise the muscles/ ,he problem is the lac of /speed0$ because although the fracture doesn1t unite slowly$ the sustained lower limb traction eeps the patient in bed for a long time$ thus increasing the li lihood of complications such as thromboembolism$ respiratory problems$ and general wea ness) 2ustained traction is best avoided in elderly patients$ and even in younger patients traction should be replaced by cast splintage or functional bracing as soon as the fractiure becomes 3stic y1)

444 Traction by gravity Eg/ ,ractures of the humerus. weight of arm supplies traction$ forearm supported in a wrist sling$ and movement at fracture site reduced by applying a /sleeve0 cast or brace to upper part of arm

>alanced Traction S0in traction. adhesive strapping 0ept in place by bandages S0eletal traction. stiff wire?pin inserted through the bone distal to the fracture 2 in traction will sustain a pull of no more than 5 or 6 g$ s eletal traction can be used to apply several times as much force$ which is needed to hold lower limb fractures ,he pin passes thru the pro"imal tibia for traction on hip$ thigh and nee in7uries and thru the distal tiba or calcaneum for tibial fractures) Cords are attached and run over pulleys at the end of the bed to hold the weights that supply the traction force) Counter traction is provided by raising the foot of the bed and relying on the opposing weight of the patient1s body) ,he limb is supported$ both for comfort and to prevent sagging at the fracture site in a type of cradle( ,homas8s splint for the femur or Braun8s frame for the tibia

***&ast splintage ;laster of ;aris. still used as splint, esp for distal limb fractures and for most children!s fractures <safe= 6not applied too tightly or unevenly7 <speed= of union same as traction, but pt goes home sooner <holding= is not a problem, and patients with tibial fractures can bear weight on the cast >ig drawbac0 is that oints encased in plaster cannot <move= and are liable to stiffen@ as the swelling and haematoma resolve$ adhesions form which bind muscle fibres to each other and to the bone) This complication can be minimiAed by.

$elayed splintage- using traction until movement has been regained, and then applying plaster Starting with a cast but after a few wee0s replacing it by a functional brace which permits oint movement

***&omplications of cast splintage )iable to appear once the patient has left the hospital@ added ris0 of delay before the problem is attended to

2/ Tight cast %) 9ut on too tightly: become tight if limb swells &) ;iffuse pain then later signs of vascular compression appear <) Elevate the limb+ if pain doesn1t subside during the ne"t hour$ split the cast open== 3/ ;ressure sores %) .ver a bony prominence &) >ocali-ed pain$ inspect through a window in the cast <) 9revented by padding all bony prominences before applying cast 4/ S0in abrasion or laceration %) Complication of removing plasters$ especially if electric saw is used 9/ )oose cast %) .nce swelling has subsided$ cast may no longer hold the fracture securely &) ?eplace it= ***,unctional bracing @sing either plaster of paris or one of the lighter materials /functional0 7oint movement less restricted than with conventional casts ;revents oint stiffness while still permitting fracture splintage and loading

2egments of a cast are applied only over the shafts of the bones$ leaving the 7oints free+ cast segments above and below a 7oint can be connected by metal or plastic hinges which allow movements in one plane) %sed most widely with fractures of the femur or tibia Since its not very rigid, it is usually applied only when the fracture is beginning to unite$ i)e) after <'A w s of traction or restrictive splintage If used in this way$ it comes out well on all four of the basic re-uirements. <hold= <move= <speed= <safe=

***internal fixation <holds= securely <movements= can begin at once 6no stiffness and edema7 <speed=. patient can leave hospital as soon as wound is healed, but full weight bearing is unsafe for some time <safety=" biggest problemB SE;S+SBBB #is0 depends on. the patient, the surgeon, the facilities

***+ndications for internal fixation ,ractures that cannot be reduced except by operation ,ractures that are inherently unstable and prone to re-displacement after reduction ,ractures that unite poorly and slowly !femoral nec # ;athological fractures !bone de may prevent healing# Multiple fractures 6early fi"ation reduces the ris complications# of general

,ractures in patients who present severe nursing difficulties

Types of internal fixation Screws. fixing small fragments onto the main bone 8ires. 6often inserted percutaneously without exposing the fracture7 when fracture healing is predictably -uic0, external splintage as supplementary support

;lates and screws. metaphyseal fractures of long bones and diaphyseal fractures of the radius and ulna +ntramedully nails. long bones

***&omplications of internal fixation Most are due to poor techni-ue, e-uipment, or operating conditions +nfection +atrogenic infection is now the most common cause of chronic osteomyelitis ,he metal doesn1t predispose to inf"n$ but the quality of the patient1s tissues and the open operatiion do If the inf"n isn1t rapildy controlled by IB antibiotics$ the implants should be replaced with some form of e"ternal fi"ation

Con-union Excessive stripping of the soft tissues unnecessary damage to the blood supply in the course of operative fixation rigid fixation with a gap between the fragments

+mplant failure *etal is sub7ect to fatigue @ndue stresses should be avoided until the fracture has united 9ain at the fr" site is a danger signal=

#efracture If metal implants are removed too soon % yr %C:&5 m1s For several wee s after implant removal the bone is wea $ so full weight'bearing should be avoided

***External ,ixation

Bone is transfi"ed above and below the fracture with screws:pins:tensioned wires and these are then clamped to a frame or connected to each other by rigid bars) ;ermits ad ustment of length and angulation, and some allow reduction of the fracture in all 4 planes/ Can be used for fractures of almost any part of the s eleton but are especially applicable to the long bones and the pelvis/ +ndications. ,ractures associated with severe soft-tissue damage where the wound can be left open for inspection, dressing, or definitive coverage/ Severely comminuted and unstable fractures, which can be held out to length until healing commences/ ,ractures of the pelvis, which often cannot be controlled -uic0ly by any other method/ ,ractures associated with nerve or vessel damage/ +nfected fractures, for which internal fixation might not be suitable/ %n-united fractures, where dead or sclerotic fragments can be excised and the remaining ends brought together in the external fixator@ sometimes this is combined with elongation in the normal part of the shaft

&omplications of external fixation 'igh degree of training and s0illB (ften used for the most difficult fractures increased li0elihood of complications $amage to soft-tissue structures ,ransfi"ing pins or wires may in7ure nerves or vessels$ or may tether ligaments and inhibit 7oint movement) 2urgeon must be familiar with the local anatomy and the /safe corridors0 for inserting pins

(ver-distraction Co contact between the fragments union delayed?prevented

;in-trac0 infection

.ne of the most troublesome complications *eticulous pin'site care Administer antibioitics immediately

***ExerciAe #estore function to the in ured parts and the patient as a whole 1ctive Exercise, 1ssisted movement 6continuous passive motion by machines7, ,unctional activity (b ectives. #estore circulation ;revent soft tissue adhesions ;romote fracture healing #educe edema Swellingtissue tension and blistering, oint stiffnes Soft Tissue care. elevate and exercise, never dangle, never force

;reserve oint movement #estore muscle power Duide patient bac0 to normal activity

***+nitial Management *ultiple in7uries$ severe shoc 1t the scene of the accident 2plint the limb cover with a sterile dressing leave undisturbed until the patient reaches the E;( reduce ris of further contamination and wound dessication

+n the hospital

?apid general assessment adress any life'threatening conditions tetanus prophyla"is !to"oid for previously immuni-ed$ human anti'serum for not# Inspect the wound( site and si-e$ tidy:ragged$ clean:dirty$ conditions of soft tissues$ circulation$ and nerve supply$ and whether it communicates with the fracture

*** Dustilo!s classification of open fractures. Type 1: low-energy fracture with a small, clean wound and little softtissue damage Type 2: moderate-energy fracture with a clean wound more than 2 cm long, but not much soft-tissue damage and no more than moderate comminution of the fracture/ Type 3: high-energy fracture with extensive damage to s0in, soft tissue and neurovascular structures, and contamination of the wound/ Type 3 A: the fractured bone can be ade-uately covered by soft tissue Type 3 B: can!t be ade-uately covered, and there is also periosteal stripping, and severe comminution of the fracture Type 3 C: if there is an arterial in ury that needs to be repaired, regardless of the amount of other soft-tissue damage/

The incidence of wound infection correlates directly with the extent of soft-tissue damage, E3F in type 2 G2HF in type 4 rises with increasing delay in obtaining soft tissue coverage of the fracture/

***1ll open fractures assumed to be contaminated ;revent infectionB The essentials. ;rompt wound debridement 1ntibiotic prophylaxis StabiliAation of the fracture Early definitive wound cover

#epeated examination of the limb because open fractures can also be associated with compartment syndrome

***Sterility and 1ntibiotic cover The wound must be 0ept covered until the patient reaches the operating theatre 1ntibiotics are given 1S1;, no matter how small the laceration$ and continued until the danger of infection has passed) Most cases. >enAylpenicillin and flucloxacillin Even better. 3nd generation cephalosporin, every I hrs?9J hrs +f the wound is heavily contaminated, cover for Dram 6-7 organisms and anaerobes by adding gentamicin or metronidaAole and continuing treatment for 9 or : days

***$ebridement and wound excision %nder D1Kin the operating theatre, never in the E#B Maintain traction on in ured limb and hold it still #emove clothing #eplace dressing with sterile pad &lean and shave surrounding s0in #emove pad and irrigate wound with 1 )(T of warm normal saline $o not use a tourni-uetB !endanger circulation even more and ma e it difficult to recogni-e which structures are devitali-ed# Extend wound and excise ragged margins healthy s0in edges #emove foreign materials and tissue debris 8ash out wound again with warm CS 6I-23 )7 6 long bone fractures especially need as much as possible# #emove devitaliAed tissue 6provides a nutrient medium for bacteria7

;ead muscle( purplish color$ failure to contract when stimulated$ failure to bleed when cut$ mushy consistencyD late feature# >est to leave cut nerves and tendons alone !although if wound absolutely clean and no dissection is required and the necessary e"pertise are provided$ they can be sutured#

Eound Closure <to close, or not to close the s0in=" difficult decision %ncontaminated types 2 and 3 wounds may be sutured operated on within a few hours of in7ury after debridement and wound e"cision without tension 1ll other wounds must be left open$ lightly pac ed with moist$ sterile gau-e$ and inspected again after &5'5C hrs( if the wound is clean and tidy$ it can then be sutured or s in'grafted !provided there is a suitable soft', bed# and this is called delayed primary closure/ Type 4 wounds may occasionally have to be debrided more than once and s0in closure may call for plastic surgery/ S0in grafting" most appropriate if the wound cant be closed w?o tension and the recipient bed is clear, free of obvious infxn, and well vasculariAed@ it is not necessary to wait until the bed is covered with granulation ,) 9artial thic ness grafts can$ if necessary$ be laid on periosteum or paratenon$ but they should not be applied directly over bare bone or tendons or metal implants

2tabili-ation of the Fracture Stability of the fracture is imp in #educing the li0elihood of infxn 1ssisting in recovery of the soft tissues

Method of fixation depends on. $egree of contamination )ength of time from in ury to operation 1mount of soft tissue damage

!if no obvious contamination and time lapse is less than C hrs# (pen fractures of all grades up to 41 treated as for closed in uries. cast splintage, internal fixation !intramedullary nailing and plating#, or external fixation !depending on the individual characteristics of the fracture and wound# More sever in uries. combined approach by plastic and ortho surgeons The precise method depends on the type of soft-tissue cover that will be employed, although external fixation using a circular frame can accommodate to most problems ;lates and screws should be reserved for metaphyseal or articular fractures and for fractures of the smaller tubular bones/

;ost-op )imb is elevated &irculation carefully monitored 1ntibiotic cover continued@ swab samples will dictate whether a diff/ antibiotic is needed +f wound has been left open, inspect in 3-4 days/ $elayed primary suture is then often safe or, if there has been much s0in loss, plastic surgery for grafting may be necessary

Teamwor0 ,or optimal results, open fractures with s0in and soft-T damage are best managed by a partnership of ortho and plastic surgeons, ideally from the outset rather than by later referral +f no plastic surgeon on site, use a digital camera for image transmission by internet to communicate and consult/