[4] Principles of Fracture Management

Question 1

What is the most important thing to remember in the surgical management in traumatic orthopaedic complaints?

Answer 1

Reduce - Hold - Rehabilitate

Question 2

What should reduce-hold-rehabilitate be precluded by in the context of high-energy injuries?

Answer 2

Resuscitation, following ATLS (advanced trauma life support) principles

Question 3

What does reduction involve?

Answer 3

Restoring the anatomical alignment of a fracture or dislocation of the deformed limb

Question 4

What does reduction allow for?

Answer 4

• 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

Question 5

What is the result of the reduction in traction on the surrounding soft tissues after a fracture or dislocation?

Answer 5

It reduces swelling

Question 6

What is the importance of reducing swelling after a fracture or dislocation?

Answer 6

Excessively swollen soft tissues have higher rates of wound complications, and surgery may be delayed to allow this to regress

Question 7

What is the result of the reduction in the traction on the traversing nerves after fracture or dislocation?

Answer 7

It reduces the risk of neuropraxia

Question 8

What is the result of the reduction of pressures on traversing blood vessels after a fracture or dislocation?

Answer 8

It restores any affected blood supply

Question 9

What is the main principle in any reduction, regardless of the method employed?

Answer 9

To correct the deforming forces that result in the injury

Question 10

What may some clinicians suggest is done before correcting the deforming forces that resulted in the injury?

Answer 10

An initial exaggeration of the fracture, before the definitive reduction manoeuvre

Question 11

Why might some clinicians suggest an initial exaggeration of the fracture before the definitive reduction manoeuvre?

Answer 11

It aids the uncoupling of the proximal and distal fracture fragments

Question 12

How is fracture reduction typically performed in the emergency setting?

Answer 12

Closed

Question 13

What are the types of fracture reductions?

Answer 13

• Closed
• Open
• Intra-operatively

Question 14

How is open fracture reduction performed?

Answer 14

By directly visualising the fracture and reducing it with instruments

Question 15

Is fracture reduction painful?

Answer 15

Yes

Question 16

What is the method of choice of analgesia in fracture reduction?

Answer 16

Regional or local blockage, where this is sufficient and easily provided

Question 17

Where is regional or local blockage likely to be sufficient and easily provided in fracture reduction?

Answer 17

Phalangeal/metacarpal/distal radius fractures

Question 18

What analgesia does a patient more commonly require during a fracture reduction?

Answer 18

Conscious sedation

Question 19

What setting does conscious sedation for fracture reduction need to take place in?

Answer 19

One that has access to anaesthetic agents, airway adjuncts, and monitoring

Question 20

What does a reduction manouvre require two people?

Answer 20

One to perform the reduction manouvre, and one to provide counter-traction

Question 21

What is meant by ‘hold’?

Answer 21

It is the generic term to describe immobilising a fracture

Question 22

What is it important to consider initially when thinking about immobilising a fracture?

Answer 22

Whether traction is needed?

Question 23

What is traction most commonly employed for in fracture immobilisation?

Answer 23

• Subtrochanteric neck of femur fractures
• Femoral shaft fractures
• Displaced acetabular fractures
• Some pelvic fractures

Question 24

When might traction be needed to immobilise fractions?

Answer 24

If the muscular pull across the fracture site is strong, and the fracture is inherently unstable

Question 25

What are the most common ways to immobilise a fracture?

Answer 25

Via simple splints or plaster casts

Question 26

What are the most important principles to consider when applying a plaster cast?

Answer 26

• For the first 2 weeks, plasters are not circumferential
• If there is axial instability, the plaster should cross the joint above and below

Question 27

What is meant by plasters being non-circumferential?

Answer 27

They must have an area which is only covered by the overlying dressing

Question 28

Why should fractures be non-circumferential for the first two weeks?

Answer 28

To allow them to swell, otherwise the patient is at risk of compartment syndrome

Question 29

What is meant by axial instability with regards to fractures?

Answer 29

If the fracture is able to rotate along its long axis

Question 30

Give two examples of fracture that have axial instability?

Answer 30

• Combined tibia/fibula metaphyseal fractures
• Combined radius/ulna metaphyseal fractures

Question 31

Do the joints above and below need to immobilised for fractures without axial instability?

Answer 31

No, for most other plasters, the plaster only needs to cross the joint immediately below it

Question 32

What is meant by rehabilitation in the management of fractures?

Answer 32

This refers to the need for most patients to undergo an intensive period of physiotherapy following fracture management

Question 33

Why is physiotherapy important following fracture?

Answer 33

Invariably, patients are stiff following immobilisation

Question 34

What is it important to consider regarding fractures and the effect on a patient?

Answer 34

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

Question 35

What is the role of therapists with frail patients who may struggle to cope at home?

Answer 35

They are essential in making sure that this group have suitable adaptations implemented for them during their recovery