basis of fracture management Flashcards
Rx depends on
stability of #
patient factors: fitness, other injuries
open vs closed
complete stability
transverse
no stability to shortening
spiral
comminuted
oblique
potential stability
oblique <45degrees
open fracture
direct communication between external environment and
usually through break in skin but not always
open fracture Rx
prophylaxis tetanus and antib
surgical emergency (all within 24hrs)
early + thorough wound excision and toilet
photograph, cover and stabilise limb
open fracture Gustilo grade I
low energy
wound <1cm
open fracture Gustilo grade II
moderate soft tissue damage
wound 1-10cm
open fracture Gustilo grade III
high energy, wound >10cm
A: soft tissue damage ++++
B: periosteal stripping
C: neurovascular complication
initial # Rx
immobilisation
pain relief
assessment
clinical: open vs closed, fracture, neurological, circulation
radiological
definitive Rx
no reduction required
reduction require - local vs general anaesthetic
maintenance of position: conservative, operative
conservative Rx: no initial immobilisation or reduction needed
no support
support: brace, elastic bandage, strapping
conservative Rx: initial immobilisation +/- reduction
cast
functional brace
traction
cast principles
3 point loading
hydraulics: circumferential restraint and longitudinal force - soft tissue wont buldge out and reduces shortening
rotation control by including joint above and below
functional bracing
for long bones e.g. femur, humerus
in cast until bone becomes sticky and then brace: bones will no longer shorten
joints free to move
traction
axial force
pulls along line of limb
tightens soft tissue sleeve and so aligns bone
closed reduction
initial reduction
maintenance of reduction
skin traction
applied via adhesive or non-adhesive tape
blistering and sloughing where traction slides off
compartment syndrome due to elevation and compression
skeletal traction
traction via bone: pin, wire
allows greater force, weight
common sites: femur, tibia
operative Rx options
internal fixation: intramedullary nailing, screws, plates
external fixation
external fixation
fixation from outside
pins/wires passed through skin and bone and fixed to external frame
external fixation indication
w poor soft tissue conditions
where distraction through fixator may help w fragment reduction
emergency pelvic stabilisation for haemorrhagic control
limb reconstruction
external fixator types
unilateral
multilateral
circular
external fixation complications
neurovascular injury
pin tract infection
loss of # alignment
additional wires
wires not attached to frames
may be used to pin fragments together
intramedullary nailing indications
long bone diaphysis e.g. femoral, tibia
IM nailing technique
reduction - check on x-ray
entry point - small incision, x-ray guided
canal reamed - wire passed down, hole made in medulla
nail passed
bone locked onto plate
IM nailing advantages
incision remote from # - less chance contamination
minimal #exposure
joints free to move
internal fixation - screws and plates
usually incision over and exposure of #
accurate # reduction
allows early joint mobilisation
access for bone grafting
internal fixation - screws and plates: risks
devascularisation - slow to heal
wound problems
infection
screws
different types for cortical and cancellous
different sizes
fix 2 pieces bone together; compress or fix in position
plate fixation
fixed to outside of bone with screws
load sharing between plate and bone
bone needs to heal before plate fails (repeated bending)
types of plates
compression: squeeze bone together
neutralisation: resist rotational forces, spiral #
buttress: stop collapse
strut/bridging: no opening of #
