Management of Fractures pptx - D. Wahby

Management of fractures

Dr. Wahby Ghalib
CABMS, FJMC, MRCS

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Reduction

Immobilization

Exercise

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The most important factor for healing is the:

state of the surrounding soft tissues &
local blood supply.

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Reduction
As soon as possible to avoid swelling

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Anatomic reduction
Intra-articular #

Physeal #

Forearm #

Tenuous blood supply (scaphoid , FN)

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Closed reduction
Anaesthesia & muscle relaxant :

Traction

Correction of deformity

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Open reduction
CR fails

Perfect reduction needed

Internal fixation intended

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Immobilization
Soft t. Healing

Faster bone healing

To avoid malunion

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Methods
(1) continuous traction
(2) cast splintage
(3) functional bracing
(4) internal fixation
(5) external fixation

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Continuous traction
Traction by gravity:

in humerus fractures : hanging cast

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Skin traction
Adhesive tape and bandage
Sustains pull of 4-5 kg

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Skeletal traction
Steinmann pin

Sustains 1/10 of body weight

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Advantage : joint exercise

Disadvantage : prolonged bed riding & hospitalization

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Complications of traction
Circulatory embarrassment : specially in children

Nerve injury by pin or external rotation position

Pin-track infection

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POP cast
Ca sulphate

On addition of water  becomes hydrated & then hardens (exothermic reaction)

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Back slab

Cast cylinder

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Polyurethane cast
Lighter
Harder
Impervious to water
Less XR interference

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Advantage : early discharge

Disadvantage : joint stiffness

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Complications
Tight cast : compartment syndrome  split or remove the cast

Loose cast : re-displacement

Plaster sores : pad bony prominances

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Functional brace
Casts applied to shafts of bones connected by hinges to allow joint motion

Made of metal or plastic

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Adv. : no joint stiffness

Disadv. : not very rigid  malunion

So: used after 3-6w

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Internal fixation
Wires (e.g. Kirschner wire)
Screws
Plates
Intra-medullary nails

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Indications
OR. Needed

Unstable #

# of poor & slow healing e.g. FN.

Pathological #

Multiple #s

Patient with nursing difficulty

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Adv. :
secure fixation
early joint motion

Disadv. :

soft t. damage
risk of infection
metal failure

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External fixation

Screws (Schanz) pass above & below the # and are connected to an external frame

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Indications
Open #

Closed # with severe s.t. damage

Infected #

# with bone loss (bone lengthening)

Pelvic fractures

Anaesthetic risk

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Complications
Nerve & vessel injury
Screw loosening
Pin-track infection

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Exercise
To ↓ oedema ( fibrous t.  stiffness)

To prevent joint stiffness

Elevation is also important

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Active vs. passive ROM exercise

Weight bearing

Continuous passive motion machine

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Treatment

of
Open Fractures

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Gustilo classification
Type I : wound < 1cm
little soft t. damage
no comminution

Type II : wound > 1 cm
moderate soft t. damage
moderate comminution
Both caused by low-energy trauma

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Type III : wound >10 cm

severe s.t. damage
severe comminution
hi-energy trauma

A: # can be covered with s.t.

B: cannot
C: arterial injury needs repair

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Incidence of infection
< 2 % in type I

> 10 % in type III

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Management
antibiotic prophylaxis

wound debridement

stabilization of the fracture

early wound cover

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Antibiotic prophylaxis
I & II  2nd generation cephalosporin
6 hourly for 2 d

III  add gentamicin & metronidazole

4-5 d

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Debridement
Wound excision (margins)

Wound extension

Wound toilet (copious saline)

Removal of F.Bs.

Removal of devitalized tissus

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Wound closure
Type I : close after debridement

Other types : inspect after 48 hours

Skin graft or flap may be needed

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# stabilization
Up to IIIA  like closed #

IIIB & C  external fixation

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Objectives :

Training the students to deal with multitrauma cases in a systemic way.
Training the students to approach injured limb according to priorities.
The useful and safe way to deal with skeletal XR.
Understanding the concept of balancing the three basic factors of fracture management.
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Stressing the significance of compound fractures and the way they are classified and managed.
Understanding the various ways of fracture management and their indications and drawbacks.
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Thank you