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Fracture treatment
A/ Reduce the fracture:Closed reductionOpen reduction
Articular fractures:Need anatomical reduction
Fracture treatment
A/ Reduce the fracture:Closed reductionOpen reduction
Articular fractures:Need anatomical reduction
Diaphyseal fracturesNeed functional reduction
Restore length, axis,
and rotation
Fracture treatment
B/ Hold reduction until healing:
Methods of holding reductionSustained tractionCast splintFunctional bracingInternal fixationExternal fixation
Fracture Management
Treatment of closed fractures
Treatment of open fractures Differe
nt
Treatment of closed fractures
Emergency care (splinting)
Definitive fracture treatment
Rehabilitationmuscle activity and early weightbearing are
encouraged
Emergency care (splinting)
Splint them where they lie
Adequate splinting is desirable
Type of splints:Improvisedconventional
Conservative
Reduction: (if displaced)under general anasthesia, the sooner the better
Steps of Reduction:TractionAlign (which fragment)Reverse mechanism of injury
Immobilization:POP (Plaster of Paris) cast, slab, traction
Rehabilitation
Closed reduction
1. Traction in the line of the bone
2. Pressing fragment into reduced position
3. Disimpaction
Absolute:when closed reduction failswhen there is an articular fragment that needs
accurate positioningfor traction (avulsion) fractures in which the
fragments are held apart
Relative:Multiple fracturesPathological fracturesTo encourage early mobilization and avoid joint
stiffness. e.g. Diaphyseal fractures
Indications of Open reduction
Type of internal fixation
Screws
Wires
Plates and screws
Intramedullary nails
Operative Vs non-operative
Criteria Operative
Non-operative
Risk of joint stiffness Low Present
Rehabilitation Rapid Slow
Risk of mal-union Low Present
Risk of non-union Present Present
Speed of healing Slow Rapid
Risk of infection Present Low
Cost ? ?
External fixation
Indications in acute trauma:Fractures associated with severe soft-tissue damage
(including open fractures) or those that are contaminated
Fractures around joints that are potentially suitable for internal fixation but the soft tissues are too swollen to allow safe surgery
Patients with severe multiple injuries
Rehabilitation
Restore function of theinjured parts and,patient as a whole
The objectives are:to reduce edema preserve joint movementrestore muscle power guide the patient back to normal activity
Treatment of open fractures
The four essentials are:Antibiotic prophylaxisUrgent wound and fracture debridementStabilization of the fracture
? External FixationEarly definitive wound cover
To be discussed separately
Complications of Fractures
Nonunion (failure to heal)3% overall50% of some particular fracturesRelated to treatment, local problems, systemic
problems (e.g. Smoking)
Complications of Fractures
Malunion: (Healing in poor position)DeformityRisk of arthritis
Complications of Fractures
Fat embolism syndromeMarrow elements (fat) released into the vascular
system and travel to the lungs Triglycerides (fat) metabolized to FFA by
pneumatocytes and these FFS are toxic to tissue Especially brain, blood vessels, kidneysARDSRisk of death
Fat Embolism
DiagnosisARDSMental status changesPetechial hemorrhageOtherTreatmentRespiratory SupportEarly recognition
Complications of Fractures
DVT/Pulmonary embolismFracture leads to immobilizationStasis, hypercoagulability, intimal injuryThrombosis of LE veinsEmbolism to heart and then lungsMechanical blockageVentilation/perfusion mismatch
DVT Prevention
MobilizationPatientLimb
MechanicalSkeletal stabilizationSCD, foot pumpsCompression
Chemical anticoagulation
Pitfalls in Fracture Management
History of mechanism of injury not obtainedCombination injury missedSoft tissue not considered
Failure to consider occult fractures
X-rays not proper; exposure, views..
Inadequate film accepted
Summary
What is a Fracture – the soft tissue part
Fracture types
Relation between fracture and force
How fractures heal
Principles of imaging
Principles of treatment
Complications of fractures