Fracture Management

Question 1

What are the principles of management in traumatic orthopaedic cases?

Answer 1

Reduce - Hold - Rehabilitate

Question 2

What is Reduction?

Answer 2

Reduction involves restoring the anatomical alignment of a fracture or dislocation of the deformed limb - correct the deforming forces that resulted in injury.

Question 3

What does reduction allow for?

Answer 3

Tamponade of bleeding at the fracture sight
Reduction in the traction on the surrounding soft tissues, reducing swelling
Reduction in traction on the traversing nerves, reducing the risk of neuropraxia
Reduction of pressures on traversing blood vessels, restoring any blood supply affected

Question 4

How is reduction performed in the emergency setting?

Answer 4

Closed however some fractures are also reduced open by directly visualising the fracture and reducing it with instruments.

Question 5

What are the clinical requirements for reduction?

Answer 5

Painful - requires analgesia
Can be regional or local blockade
Or a short period of conscious sedation
Specific manoeuvre requires 2 people - one to perform the reduction manoeuvre and one to provide counter-traction

Question 6

What is hold?

Answer 6

Hold is the term used to describe immobilising the fracture

Question 7

What must be considered when immobilising a fracture?

Answer 7

Whether traction is needed - muscular pull across fracture site may be strong, making the fracture unstable

Question 8

What are the most common ways to immobilise a fracture?

Answer 8

Simple splints or plaster casts

Surgical intervention may be the definitive method of holding

Question 9

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

Answer 9

For the first 2 weeks, plasters are not circumferential - they must have an area which is only covered by the overlying dressing, to allow the fracture to swell - otherwise there is risk of compartment syndrome.

If there is axial instability (fracture is able to rotate along its long axis - e.g. combined tibia/fibula metaphysical fractures) plaster should cross both the joint above and below the fracture. For most other fractures, the plaster need only cross the joint immediately distal to it.

Question 10

What should you consider in fracture immobilisation?

Answer 10

Can the patient weight bear?
Does the patient need thromboprophylaxis?
Advice about the symptoms of compartment syndrome.

Question 11

What is rehabilitation?

Answer 11

Intensive period of physiotherapy following fracture management.
Patients are stiff following immobilisation.

Question 12

What is it important to advise patients?

Answer 12

Move non-immobilised unaffected joints

Question 13

How can bony injuries occur?

Answer 13

Trauma (excessive forceS)
Stress (repetitive low velocity injury)
Pathological (abnormal bone which fractures during normal use or minimal trauma)

Question 14

What are 5 types of fracture?

Answer 14

Oblique - fracture lies obliquely to long axis of bone
Comminuted (>2 fragments)
Segmental - more than one fracture along a bone
Transverse - perpendicular to long axis of bone
Spiral - severe oblique fracture with rotation along long axis of bone

Question 15

What classification to distinguish between open/closed fracture?

Answer 15

Gustillo-Anderson
1 - low energy wound <1cm
2 - greater than 1cm wound with moderate soft tissue damage
3 - high energy wound >1cm with extensive soft tissue damage
3A - adequate soft tissue coverage
3B - inadequate soft tissue coverage
3C Associated vascular injury

Question 16

What are the key points in assessment and management of fracture?

Answer 16

Assessment:
Plain radiograph - AP and lateral - displacement/angulation
Assess joint above and below
Neuromuscular compromise
Signs of pathological fracture
type of fracture
Foreign body?

Management
Reduce
Immobilise including proximal and distal joints
NV status following reduction and immobilisation
Infection with tetanus prophylaxis and IV broad spectrum abs for open injuries
Debridement of open fractures and lavage within 6 hours