1reaLmenL of lracLures

repared by
Cla Ahmad AbuLaban
20032010036
Cp u1
rlnclples of 1reaLmenL
W 1reaL Lhe aLlenL noL only Lhe fracLure
W 1reaLmenL of Lhe fracLure
ManlpulaLlon
SpllnLage
!olnL movemenL and funcLlon musL be preserved
Lxerclse and early welghL bearlng
Maln ob['s 8LuuCL! PCLu! LxL8ClSL!
1he lracLure CuarLeL
W uual ConfllcL
Pold vs Move
Speed vs SafeLy
Closed lracLures
8LuuC1lCn
W no undue delay ln aLLendlng Lo Lhe fracLure
W 8educLlon unnecessary when
1here ls llLLle or no dlsplacemenL
ulsplacemenL does noL maLLer
8educLlon ls unllkely Lo succeed
W Alm of reducLlon
AdequaLe apposlLlon
normal allgnmenL of Lhe bone fragmenLs
W MeLhods of reducLlon
ManlpulaLlon
Mechanlcal LracLlon
Cpen operaLlon
1 ManlpulaLlon
W Closed manlpulaLlon ls sulLable for
1 All mlnlmally dlsplaced fracLures
2 MosL fracLures ln chlldren
3 lracLures LhaL are llkely Lo be sLable afLer reducLlon
W unsLable fracLures are someLlmes reduced 'closed'
prlor Lo mechanlcal flxaLlon
W 1hree fold maneuver under anesLhesla and muscle
relaxaLlon
1 1he dlsLal parL of Lhe llmb ls pulled ln Lhe llne of Lhe bone
2 1he fragmenLs are reposlLloned as Lhey dlsengage
3 AllgnmenL ls ad[usLed ln each plane
2 Mechanlcal 1racLlon
W Some fracLures are dlfflculL Lo reduce by
manlpulaLlon
W 1hey can ofLen be reduced by susLalned
mechanlcal LracLlon whlch Lhen serves also Lo
ho|d Lhe fracLure unLll lL sLarLs Lo unlLe
W ln some cases rapld mechanlcal LracLlon ls
applled prlor Lo lnLernal flxaLlon
3 Cpen CperaLlon
W CperaLlve reducLlon under dlrecL vlslon ls lndlcaLed
1 When closed reducLlon falls
2 When Lhere ls a large arLlcular fragmenL LhaL needs
accuraLe poslLlonlng
3 lor avulslon fracLures ln whlch Lhe fragmenLs are held
aparL by muscle pull
4 When an operaLlon ls needed for assoclaLed ln[urles
3 When a fracLure wlll anyhow need lnLernal flxaLlon Lo
hold lL
Pold
W 8esLrlcLlon of movemenL
revenLlon of dlsplacemenL
AllevlaLlon of paln
romoLe sofLLlssue heallng
1ry Lo allow free movemenL of Lhe unaffecLed parLs
W SpllnL Lhe fracLure noL Lhe enLlre llmb
W MeLhods of holdlng reducLlon
SusLalned LracLlon
CasL spllnLage
luncLlonal braclng
lnLernal flxaLlon
LxLernal flxaLlon
W Closed vs operaLlve meLhods
1 SusLalned 1racLlon
W 1racLlon ls applled Lo Lhe llmb dlsLal Lo Lhe fracLure so
as Lo exerL a conLlnuous pull ln Lhe long axls of Lhe
bone
W ln mosL cases a counLerforce wlll be needed
W arLlcularly useful for splral fracLures of longbone
shafLs whlch are easlly dlsplaced by muscle
conLracLlon
W 1he hold" ls noL perfecL buL lL ls safe" and Lhe
paLlenL can move" Lhe [olnLs and exerclse Lhe muscles
W 1he problem ls Lhe lack of speed"compllcaLlons
W 1racLlon by gravlLy
Lg lracLures of Lhe humerus
W 8alanced 1racLlon
Skln LracLlon adheslve sLrapplng kepL ln place by
bandages
SkeleLal LracLlon sLlff wlre/pln lnserLed Lhrough
Lhe bone dlsLal Lo Lhe fracLure
emur fracture managed w|th ske|eta|
tract|on and use of a Ste|nmann p|n |n the
d|sta| femur
2 CasL SpllnLage
W lasLer of arls sLlll used as spllnL esp for dlsLal llmb fracLures and
for mosL chlldren's fracLures
W safe" (noL applled Loo LlghLly or unevenly)
W speed" of unlon same as LracLlon buL pL goes home sooner
W holdlng" ls noL a problem and paLlenLs wlLh Llblal fracLures can
bear welghL on Lhe casL
W 8lg drawback ls LhaL [olnLs encased ln plasLer cannoL move" and
are llable Lo sLlffen 1hls compllcaLlon can be mlnlmlzed by
1 uelayed spllnLage uslng LracLlon unLll movemenL has been
regalned and Lhen applylng plasLer
2 SLarLlng wlLh a casL buL afLer a few weeks replaclng lL by a funcLlonal
brace whlch permlLs [olnL movemenL
W CompllcaLlons of casL spllnLage
Llable Lo appear once Lhe paLlenL has lefL Lhe
hosplLal added rlsk of delay before Lhe problem ls
aLLended Lo
1 1lghL casL
2 ressure sores
3 Skln abraslon or laceraLlon
4 Loose casL
3 luncLlonal 8raclng
W revenLs [olnL sLlffness whlle sLlll
permlLLlng fracLure spllnLage and loadlng
W MosL commonly for fracLures of Lhe femur or
Llbla
W Slnce lLs noL very rlgld lL ls usually applled
only when Lhe fracLure ls beglnnlng Lo unlLe
Comes ouL well on all four of Lhe baslc
requlremenLs hold" move" speed" safe"
4 lnLernal llxaLlon
W holds" securely wlLh preclse reducLlon
W movemenLs" can begln aL once (no sLlffness
and edema)
W speed" paLlenL can leave hosplLal as soon as
wound ls healed buL full welghL bearlng ls
unsafe for some Llme
W safeLy" blggesL problem! SLSlS!!!
8lsk depends on Lhe paLlenL Lhe surgeon Lhe
faclllLles
W lndlcaLlons for lnLernal flxaLlon
1 lracLures LhaL cannoL be reduced excepL by
operaLlon
2 lracLures LhaL are lnherenLly unsLable and prone Lo
redlsplacemenL afLer reducLlon
3 lracLures LhaL unlLe poorly and slowly
4 aLhologlcal fracLures
3 MulLlple fracLures
6 lracLures ln paLlenLs who presenL severe nurslng
dlfflculLles
1 lnLerfragmenLary/Lag
Screws
4 llxlng small
fragmenLs onLo Lhe
maln bone
2 klrschner Wlres
4 Pold fragmenLs LogeLher where
fracLure heallng ls predlcLably
qulck
3 laLes and screws
4 MeLaphyseal
fracLures of long
bones
4 ulaphyseal
fracLures of Lhe
radlus and ulna
4 lnLramedullary nalls
4 Long bones
4 Locklng screwsreslsL roLaLlonal forces
4 1
W CompllcaLlons of lnLernal flxaLlon
MosL are due Lo poor Lechnlque equlpmenL or operaLlng
condlLlons
lnfecLlon
W laLrogenlc lnfecLlon ls now Lhe mosL common cause of chronlc
osLeomyellLls
nonunlon
W Lxcesslve sLrlpplng of Lhe sofL Llssues
W unnecessary damage Lo Lhe blood supply ln Lhe course of
operaLlve flxaLlon
W rlgld flxaLlon wlLh a gap beLween Lhe fragmenLs
lmplanL fallure
8efracLure
3 LxLernal llxaLlon
W ermlLs ad[usLmenL of lengLh and angulaLlon
W Some allow reducLlon of Lhe fracLure ln all 3 planes
W Lspeclally appllcable Lo Lhe long bones and Lhe pelvls
W lndlcaLlons
1 lracLures assoclaLed wlLh severe sofLLlssue damage where Lhe wound can be
lefL open for lnspecLlon dresslng or deflnlLlve coverage
2 Severely commlnuLed and unsLable fracLures whlch can be held ouL Lo lengLh
unLll heallng commences
3 lracLures of Lhe pelvls whlch ofLen cannoL be conLrolled qulckly by any oLher
meLhod
4 lracLures assoclaLed wlLh nerve or vessel damage
3 lnfecLed fracLures for whlch lnLernal flxaLlon mlghL noL be sulLable
6 ununlLed fracLures where dead or scleroLlc fragmenLs can be exclsed and Lhe
remalnlng ends broughL LogeLher ln Lhe exLernal flxaLor someLlmes Lhls ls
comblned wlLh elongaLlon ln Lhe normal parL of Lhe shafL
W CompllcaLlons of exLernal flxaLlon
W Plgh degree of Lralnlng and sklll! CfLen used for Lhe
mosL dlfflculL fracLures lncreased llkellhood of
compllcaLlons
uamage Lo sofLLlssue sLrucLures
CverdlsLracLlon
W no conLacL beLween Lhe fragmenLs unlon
delayed/prevenLed
lnLrack lnfecLlon
Lxerclse
W 8esLore funcLlon Lo Lhe ln[ured parLs and Lhe paLlenL as a who|e
W AcLlve Lxerclse AsslsLed movemenL (conLlnuous passlve moLlon by
machlnes) luncLlonal acLlvlLy
W Cb[ecLlves
8esLore clrculaLlon
revenL sofL Llssue adheslons
romoLe fracLure heallng
8educe edema
W SwelllngLlssue Lenslon and bllsLerlng [olnL sLlffnes
W SofL 1lssue care elevaLe and exerclse never dangle never force
reserve [olnL movemenL
8esLore muscle power
Culde paLlenL back Lo normal acLlvlLy
CLn l8AC1u8LS
W lnlLlal ManagemenL
AL Lhe scene of Lhe accldenL
ln Lhe hosplLal
1ypes of Cpen lracLures
W CusLllo's classlflcaLlon of open fracLures
1ype 1 lowenergy fracLure wlLh a small clean wound and llLLle sofL
Llssue damage
1ype 2 moderaLeenergy fracLure wlLh a clean wound more Lhan 1 cm
long buL noL much sofLLlssue damage and no more Lhan moderaLe
commlnuLlon of Lhe fracLure
1ype J hlghenergy fracLure wlLh exLenslve damage Lo skln sofL Llssue
and neurovascular sLrucLures and conLamlnaLlon of Lhe wound
W 1ype J A Lhe fracLured bone can be adequaLely covered by sofL Llssue
W 1ype J 8 can'L be adequaLely covered and Lhere ls also perlosLeal sLrlpplng
and severe commlnuLlon of Lhe fracLure
W 1ype J c lf Lhere ls an arLerlal ln[ury LhaL needs Lo be repalred regardless of
Lhe amounL of oLher sofLLlssue damage
1he lncldence of wound lnfecLlon
correlaLes dlrecLly wlLh Lhe exLenL of sofLLlssue damage 2 ln Lype 1 10
ln Lype 3
rlses wlLh lncreaslng delay ln obLalnlng sofL Llssue coverage of Lhe fracLure
rlnclples of 1reaLmenL of Cpen
lracLures
W All open fracLures assumed Lo be conLamlnaLed
revenL lnfecLlon!
W 1he essenLlals
rompL wound debrldemenL
AnLlbloLlc prophylaxls
SLablllzaLlon of Lhe fracLure
Larly deflnlLlve wound cover
8epeaLed examlnaLlon of Lhe llmb because open
fracLures can also be assoclaLed wlLh comparLmenL
syndrome
SLerlllLy and AnLlbloLlc cover
W 1he wound musL be kepL covered unLll Lhe
paLlenL reaches Lhe operaLlng LheaLre
W AnLlbloLlcs ASA
W MosL cases 8enzylpenlclllln and flucloxaclllln
W Lven beLLer 2
nd
generaLlon cephalosporln every
6 hrs/48 hrs
W lf heavlly conLamlnaLed cover for Cram ()
organlsms and anaerobes by addlng genLamlcln
or meLronldazole and conLlnulng LreaLmenL for 4
or 3 days
uebrldemenL and Wound Lxclslon
W ln Lhe operaLlng LheaLre never ln Lhe L8!
W under CA
W MalnLaln LracLlon on ln[ured llmb and hold lL sLlll
W 8emove cloLhlng
W 8eplace dresslng wlLh sLerlle pad
W Clean and shave surroundlng skln
W 8emove pad and lrrlgaLe wound wlLh A LC1 of warm normal sallne
W uo noL use a LournlqueL!
W LxLend wound and exclse ragged marglns healLhy skln edges
W 8emove forelgn maLerlals and Llssue debrls
W Wash ouL wound agaln wlLh warm nS (612 L)
W 8emove devlLallzed Llssue
W 8esL Lo leave cuL nerves and Lendons alone
Wound Closure
W Lo close or noL Lo close" Lhe skln dlfflculL
declslon
unconLamlnaLed Lypes 1 and 2 wounds may be
suLured
All oLher wounds delayed prlmary closure
1ype 3 wounds may occaslonally have Lo be debrlded
more Lhan once and skln closure may call for plasLlc
surgery
Skln grafLlng mosL approprlaLe lf Lhe wound canL be
closed w/o Lenslon and Lhe reclplenL bed ls clear free
of obvlous lnfxn and well vascularlzed
SLablllzaLlon of Lhe lracLure
W SLablllLy of Lhe fracLure ls lmp ln
8educlng Lhe llkellhood of lnfxn
AsslsLlng ln recovery of Lhe sofL Llssues
W MeLhod of flxaLlon depends on
uegree of conLamlnaLlon
LengLh of Llme from ln[ury Lo operaLlon
AmounL of sofL Llssue damage
W Cpen fracLures of all grades up Lo 3A LreaLed as for closed ln[urles
W More severe ln[urles comblned approach by plasLlc and orLho
surgeons
1he preclse meLhod depends on Lhe Lype of sofLLlssue cover LhaL wlll
be employed alLhough exLernal flxaLlon uslng a c|rcu|ar frame can
accommodaLe Lo mosL problems
AfLercare and 1eam Work
W osLop
Llmb ls elevaLed
ClrculaLlon carefully monlLored
AnLlbloLlc cover conLlnued swab samples wlll dlcLaLe wheLher a
dlff anLlbloLlc ls needed
lf wound has been lefL open lnspecL ln 23 days uelayed
prlmary suLure ls Lhen ofLen safe or lf Lhere has been much skln
loss plasLlc surgery for grafLlng may be necessary
W 1eamwork
lor opLlmal resulLs open fracLures wlLh skln and sofL1 damage
are besL managed by a parLnershlp of orLho and plasLlc
surgeons ldeally from Lhe ouLseL raLher Lhan by laLer referral
lf no plasLlc surgeon on slLe use a dlglLal camera for lmage
Lransmlsslon by lnLerneL Lo communlcaLe and consulL