Fracture management -Basic

Department Of Orthopaedics & Traumatology. Sheed Suhrawardy Medical College Hospital, Dhaka-1207, Bangladesh.

BONEFracture Management

CME on -Basic of

From -

Presenting By- Dr. Nabarun Biswas & Dr. Golam Mahamud Suhash,

From Department Of Orthopedic & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka-1207. Bangladesh.

Prepared By-Dr. Md Nazrul IslamMBBS, M . sc. (B M E).

BONEFracture Management-Basic.

Definitions

Fracture

A break in the structural continuity of bone (but we have to remember that there is always some degree of soft tissue injury with a fracture)

Goals of fracture treatment

• Prevent fracture and soft tissue complications

• Get fracture to heal and in satisfactory position for optimal functional recovery

• Intra-articular fracture needs accurate reduction & rigid fixation but non articular fracture of bone require anatomical reduction & stable fixation.

• Rehabilitate as early as possible by active & passive exercises.

• Restore patient to optimal functional state

How fracture happen

1. A single traumatic incident;

2. Repetitive stress;

3. Abnormal weakening of the bone (pathological fracture).

How fracture happen..

1. Twisting causes a spiral fracture;2. Compression causes a short oblique fracture;3. Bending results in fracture with a triangular

'butter-fly‘ fragment;4. Tension tends to break the bone transversely;

Types Of Bone Fracture (Anatomical over view)

Types of Fracture…cont.

• Open fracture :

When the bony fragments are exposed to external environment by means of wound

• Closed fracture :

The fracture fragments are not exposed to outside

Types Of Injury

High energy

Low energy

Open (compound) fractures

• Gustilo classificationType 1 – Low energy, wound <1cm (usually penetrating injury by bony fragments from inside )

Type 2 – Wound >1cm with moderate soft tissue damage

Type 3 – High energy wound >1cm with extensive soft tissue damage

Type 3A – Adequate soft tissue coverType 3B – extensive soft tissue

injury with external or internal degloving injury which needs flap coverage.

Type 3C – any open fracture associated with neuro-vascular injury.

Complications of fractures

• General complications– Shock– ARDS– Fat embolism– Head, chest, abdomen and pelvic

injuries– Crush syndrome– Tetanus– Gas gangrene– Infections – UTI, Chest– DVT/PE– Bed sores– Depression/PTSD

Complications of fractures

• Early– Visceral injury– Vascular injury– Compartment syndrome (later Volkmann

conctracture)– Nerve injury– Haemarthrosis– Infection

Late• Delayed union• Non-union• Mal-union• Tendon rupture• Myositis ossificans• Osteonecrosis• Algodystrophy• Osteoarthritis and

joint stiffness

Management of the injured patient

• Don’t treat the X-rays of the fracture, but treat the patient

• Life saving measures– Diagnose and treat life threatening

injuries (head injuries, Chest & abdominal injuries)

– Emergency orthopaedic involvement • Life saving• Complication saving

• Emergency orthopaedic management (day 1)

• Monitoring of fracture (days to weeks)• Rehabilitation and treatment of

complications (weeks to months)

Life saving measures• A= Airway and cervical

spine immobilisation• B = Breathing• C = Circulation

(treatment and diagnosis of cause)

• D = Disability (head injury)

• E = Exposure (musculo-skeletal injury)

Treatment principle of fracture

• Reduction• Maintain reduction (+ hold

until union)• Rehabilitate – restore function

by movement of the joint & patient itself.

• Prevent or treat complications

Open (compound) fractures

• High risk of infection• Can be associated with

gross soft tissue damage, severe haemorrhage or vascular injury

Open (compound) fractures - management

• While contacting orthopaedic team for definitive surgical treatment

• Irrigate wound with N.saline, if not available with tap water. Cover wound with sterile moist dressing.

• Immobilise limb preferable with external fixator if not possible , by pos. cast(including joint above & below)

• Remove obvious contaminants with meticulous effort

• Take photos• IV antibiotics (e.g. cefuroxime +/-

metronidazole or gentamicin)• Tetanus prophylaxis. • Check distal neurovascular status• Re-assess

Reduction

• If necessary, what reduction technique?

1) Closed reduction– Need anaesthesia/sedation, analgesia,

x-ray facilities, equipment, knowledge– Used for minimally displaced fractures

and most fractures of children• Distal part of limb pulled in line of

bone• Alignment adjusted in each plane

2) Open reduction– Above + theatre staff + additional

equipment– Risks

Maintain reduction• Necessary?

1) Relieve pain 2) Prevent mal-union –

nature heals the fracture, we keep it in a good position

3) Minimise non-union – maintenance of reduction should be continuous

Maintain reduction

• How?– 1) External method

• POP (+ equivalents), traction, external fixator

– 2) Internal method• Wires, pins, plates, nails,

screws

Maintain reduction – external method

• 1) POP

• Mould with palms– Adv – cheap,easy to

use, convenient, can be moulded

– Disadv – susceptibility to damage (disintegrates when wet), up to 48hrs to dry , difficulty to care of open wound

Maintain reduction–external method 2) Resin cast

• Adv – lighter and stronger, more resistant to damage, sets in 5-10mins, max strength in 30mins

• Disadvantage – cost, more difficult to apply/remove, more rigid with greater risk of complications eg. swelling and pressure necrosis

Maintain reduction – external method

• 3) Surface traction– Temporary measure

when operative fixation not available for awhile

– Skin can be injured if applied for long periods of time

– Neuro-vascular status should be checked during surface traction period

Maintain reduction – external method-

• 4) Skeletal traction– Requires invasive

procedure for longer term traction requiring heavier weights

– Complications associated with pin insertion eg. infection

Maintain reduction – external method-

• 5) External fixator• Indications

– Fractures associated with soft tissue injury

– Fracture associated with N/V damage

– Severely comminuted and unstable fracture

– Unstable pelvic fracture– Infected fracture– For skin graft & flap

coverage

• Complications– Pin track infection– Delayed union

Maintain reduction – internal method

• Advantages– Restoration of absolute anatomical state– Shorter hospital stay– Enables individuals to return to function

earlier• Indications

– Fractures that need operative fixation– Inherently unstable fractures prone to re-

displacement after reduction (eg. mid-shaft femoral fractures)

– Pathological fracture– Polytrauma (minimise ARDS)– Patients with nursing difficulties

(paraplegics, v. elderly, multiple trauma)

Maintain reduction – internal method

• By.. Nail , plate , screws, ware.

• Complications– Infection– Non-union– Implant failure– Re-fracture

Maintain reduction – internal method

• Wires & pins– Can be used in

conjunction with other forms of internal fixation

– Used to treat fractures of small bones

Maintain reduction – internal method

• Plates & screw– Extend along the

bone and screwed in place

– May be left in place or removed (in selected cases) after healing is complete

Maintain reduction – internal method

• Nail or rods– Held in place by

screws until the fracture is healed

– May be left in the bone after healing is completed

Stages of Fracture Healing

• Inflammation & Hematoma

• Callus Formation• Woven Bone• Remodeling

Types of fracture healing

• Primary : healing of the bone occur by interstitial growth of bone in rigid fixation by plate or nail

• Secondary : healing occurs with adequate callus formation both interstitial & surrounding, when micro movement occur in stable fixation by POP, cast, locking plate, external fixator.– Modern concept is …secondary

healing is preferable except intra-articular fracture

Factors Influencing Healing

• Age • Hormones • Functional activity• Nerve function• Nutrition • Drugs (NSAID)

Systemic Factors

Factors Influencing Healing…cont.

• Energy of trauma• Degree of bone loss• Vascular injury• Infection • Type of bone fractured• Degree of immobilization• Pathological condition

Local Factors

Fracture healing - operative

1) Reduction and compressionPrimary bone healingSlow process, rehabilitation rapid, high risk

2) Nailing or external fixationHealing by callusRapid process, rehabilitation rapid, lesser

risk

Healing Complications

• Delayed union• Nonunion• Malunion• Post -traumatic arthritis• Growth abnormalities• Fracture diseases- joint

stiffness, non-uses atrophy, Sudeck osteo-dystrophy,

Follow up of treatment by POP

• Judge each case on its own merits• Sticky – “Deformable but not

displaceable”• Union (weeks)

– Incomplete repair; Part moves as one; Local tenderness; Local pain on stress; See fracture line on-x-ray

• Consolidation (months)– Complete repair; No external

protection needed; Upper limb 6/52; Lower limb 12/52; Half for child; Double for transverse fractures

• Remodelling (years) successfully occur in growing skeleton .

Indications for operative treatment

– Current absolute indications:• Polytrauma; Displaced intra-articular

fractures• Open fractures with vascular injury or

compartment syndrome• Pathological fractures and non-union

– Current relative indications:• Loss of position with closed method;

Poor functional result with non-anatomical reduction; Displaced fractures with poor blood supply

Rehabilitation

• Restore the patient as close to pre-injury functional level as possible

• Rest, Elevation, Mobilisation (active/passive)

• Physiotherapy, • Work assessment and re-

employment

Special Thanks to -Incepta Pharmaceuticals Ltd.Bangladesh

THANK YOU ALL