Principles of Fractures

PRINCIPLES OF FRACTURE MANAGEMENT

CONTENT

DEFINITION
PRINCIPLES OF MANAGEMENT
- classification of fractures
- displacement types
- fracture healing
- principles of treatment
COMPLICATIONS

DEFINITION

CAUSES OF FRACTURES
• Sudden trauma
Direct : ( Transverse fracture of the tibia caused by a car hit )
Indirect : ( spiral fractures of the tibia and fibula due to torsion of the leg, vertebral compression fractures, avulsion fractures)
• Stress or fatigue-repetitive stress(athletes, dancers, army recruits)
• Pathological(osteoporosis, Paget’s disease, bone tumors)


FRACTURE CLASSIFICATION
According to presence of a wound
- closed fractures
- open fractures
According to completeness
- complete ( subdivided according to the geometry into transverse , oblique , spiral , comminuted , segmental )
- incomplete
According to AO ( usually for academic purposes)

COMPLETE FRACTURES

INCOMPLETE FRACTURE

FRACTURES DISPLACEMENT

Why complete fracture fragments displace :
by the force of injury
by gravity
by the pull of muscles attached to them.

Types of fracture displacement

4 types :
Translation/Shift
Alignment/Angulation
Rotation/Twist
Altered length ( shortening or distraction )

• SHIFT

• ANGULATION /TILT
• TWIST/
• ROTATION
•

SIDEWAYS

OVERLAP
IMPACTION

FRACTURE DIAGNOSIS

Clinical assessment
Pain
Deformity
Swelling
Impaired function
Tenderness

RADIOLOGICAL ASSESSMENT

• Plain radiography : ( rule of 2 )
2 Views
2 joints
2 limbs
2 occasions


2- CT scan : such as in palvic and spine fractures and in intra articular fracures

3- MRI : to assess the associated injuries ( spine)

4- Bone scan : like in stress fracture

How fracture heals ?

PRINCIPLES OF FRACTURE TREATMENT

Treatment of fractures

ATLS ( Advanced trauma life support )
Splint the fracture
Associated injuries
- Vascular injuries
- Nerve injuries
Decide for definitive treatment


AO PRINCIPLES
• Anatomic reduction
Fracture reduction and fixation to restore functional anatomical relationships.
2. Stable fixation
Stability by rigid fixation or splintage, as the personality of the fracture and the injury requires

3. Preservation of blood supply

Preservation of the blood supply to soft tissue and bone by careful handling and gentle reduction techniques.
4. Early mobilization
Early and safe mobilization of the part and patient.

Principle Of Treatment

The Fracture Quartet

Outline

Reduce
Aim for adequate apposition and normal alignment of the bone fragments
The greater contact surface area between fragments, the more likely is healing to occur


Reduction

Closed Reduction

Suitable for
Minimally displaced fractures
Most fractures in children
Fractures that are likely to be stable after reduction
Most effective when the periosteum and muscles on one side of fracture remain intact

Mechanical Traction

Some fractures (example fracture of femoral shaft) are difficult to reduce by manipulation because of powerful muscle pull
However, they can be reduced by sustained mechanical traction.

Open Reduction

Operative reduction under direct vision
Indications:
When closed reduction fails
When there is a large articular fragment that needs accurate positioning
When an operation is needed for associated injuries
When a fracture needs an internal fixation

Hold

WHY TO HOLD

HOLD

Sustained Traction
Traction is applied to limb distal to the fracture
To exert continuous pull along the long axis of the bone

Disadvantage and complications

Patient kept on bed for long time
Pressure ulcer
General weakness
Pulmonary infection
Contracture
Pin tract infection
Thromboembolic event


Methods
Traction by gravity
Balanced traction
Fixed traction

Traction By Gravity

Example:
Fracture of humerus
Weight of arm to supply traction
Forearm is supported in a wrist sling

Balanced Traction

SKELETAL TRACTION

Fixed Traction

Useful for when patient has to be transported
Thomas’s splint

Cast Splintage

TYPES:
Plaster of Paris
Fibreglass
Especially for distal limb # and for most children #
Disadvantage: joint encased in plaster cannot move and liable to stiffen

Complications

COMPLICATIONS OF CAST

Functional Bracing

Functional brace

Functional brace

INTERNAL FIXATION

Indications

advantages

EXTERNAL FIXATION

Principle

Indications

Advantages

Exercise ( rehabilitation )
Prevention of edema
active exercise and elevation
Active exercise also stimulates the circulation. Prevents soft-tissue adhesion and promotes fracture healing.
Preserve the joint movement
Restore muscle power
Functional activity


Open Fractures
A break in skin and underlying soft tissues leading directly to communicating with the fracture

Emergency Management of Open Fracture

A,B,C
Splint the limb
Sterile cover - prevent contamination
Look for other associate injury
Check distal circulation – is distal circulation satisfactory?
Check neurology – are the nerve intact?
AMPLE history- Allergies, Medications, Past medical history, Last meal, Events

69

Relieve pain

Tetanus prophylaxis
Antibiotics
Washout / Irrigation
Wound debridement
fracture stabilization ( according to grade)
Deal with soft tissue and skin injury.

Classification of open fractures