[4] Principles of Fracture Management Flashcards
What is the most important thing to remember in the surgical management in traumatic orthopaedic complaints?
Reduce - Hold - Rehabilitate
What should reduce-hold-rehabilitate be precluded by in the context of high-energy injuries?
Resuscitation, following ATLS (advanced trauma life support) principles
What does reduction involve?
Restoring the anatomical alignment of a fracture or dislocation of the deformed limb
What does reduction allow for?
- Tamponade of bleeding at the fracture site
- Reduction in the traction of the surrounding soft tissues
- Reduction in traction on the transversing nerves
- Reduction of pressures on traversing blood vessels
What is the result of the reduction in traction on the surrounding soft tissues after a fracture or dislocation?
It reduces swelling
What is the importance of reducing swelling after a fracture or dislocation?
Excessively swollen soft tissues have higher rates of wound complications, and surgery may be delayed to allow this to regress
What is the result of the reduction in the traction on the traversing nerves after fracture or dislocation?
It reduces the risk of neuropraxia
What is the result of the reduction of pressures on traversing blood vessels after a fracture or dislocation?
It restores any affected blood supply
What is the main principle in any reduction, regardless of the method employed?
To correct the deforming forces that result in the injury
What may some clinicians suggest is done before correcting the deforming forces that resulted in the injury?
An initial exaggeration of the fracture, before the definitive reduction manoeuvre
Why might some clinicians suggest an initial exaggeration of the fracture before the definitive reduction manoeuvre?
It aids the uncoupling of the proximal and distal fracture fragments
How is fracture reduction typically performed in the emergency setting?
Closed
What are the types of fracture reductions?
- Closed
- Open
- Intra-operatively
How is open fracture reduction performed?
By directly visualising the fracture and reducing it with instruments
Is fracture reduction painful?
Yes
What is the method of choice of analgesia in fracture reduction?
Regional or local blockage, where this is sufficient and easily provided
Where is regional or local blockage likely to be sufficient and easily provided in fracture reduction?
Phalangeal/metacarpal/distal radius fractures
What analgesia does a patient more commonly require during a fracture reduction?
Conscious sedation
What setting does conscious sedation for fracture reduction need to take place in?
One that has access to anaesthetic agents, airway adjuncts, and monitoring
What does a reduction manouvre require two people?
One to perform the reduction manouvre, and one to provide counter-traction
What is meant by ‘hold’?
It is the generic term to describe immobilising a fracture
What is it important to consider initially when thinking about immobilising a fracture?
Whether traction is needed?
What is traction most commonly employed for in fracture immobilisation?
- Subtrochanteric neck of femur fractures
- Femoral shaft fractures
- Displaced acetabular fractures
- Some pelvic fractures
When might traction be needed to immobilise fractions?
If the muscular pull across the fracture site is strong, and the fracture is inherently unstable
What are the most common ways to immobilise a fracture?
Via simple splints or plaster casts
What are the most important principles to consider when applying a plaster cast?
- For the first 2 weeks, plasters are not circumferential
- If there is axial instability, the plaster should cross the joint above and below
What is meant by plasters being non-circumferential?
They must have an area which is only covered by the overlying dressing
Why should fractures be non-circumferential for the first two weeks?
To allow them to swell, otherwise the patient is at risk of compartment syndrome
What is meant by axial instability with regards to fractures?
If the fracture is able to rotate along its long axis
Give two examples of fracture that have axial instability?
- Combined tibia/fibula metaphyseal fractures
- Combined radius/ulna metaphyseal fractures
Do the joints above and below need to immobilised for fractures without axial instability?
No, for most other plasters, the plaster only needs to cross the joint immediately below it
What is meant by rehabilitation in the management of fractures?
This refers to the need for most patients to undergo an intensive period of physiotherapy following fracture management
Why is physiotherapy important following fracture?
Invariably, patients are stiff following immobilisation
What is it important to consider regarding fractures and the effect on a patient?
Many fractures occur in frailty, and render the patient with an inability to weight bear or use an arm, having profound effects on their ability to cope at home
What is the role of therapists with frail patients who may struggle to cope at home?
They are essential in making sure that this group have suitable adaptations implemented for them during their recovery
