Fracture Management

Question 1

The 4 Rs of fracture management

Answer 1

• Resuscitation
• Reduction
• Restriction
• Rehabilitation

Question 2

Resuscitation

Answer 2

• Principles
  
  • ABCDE
  • Primary survey and trauma series
  • Fractures usually assessed in secondary survey
  • Consider reduction and splinting before imaging
    
    • Reduce pain, bleeding and risk of neurovascular injury
  • X-ray once stable
• Open fractures require the 6 As
  
  • Analgesia
  • Assess - NV status, soft tissues, photography
  • Antisepsis
  • Alignment
  • Anti-tetanus
  • Antibiotics
• Gustillo classification in open fractures
  
  • 1) Wound <1cm
  • 2) Wound ≥1cm with minimal soft tissue damage
  • 3) Extensive soft tissue damage
• Clostridium perfringes
  
  • Most dangerous complication of open facture
  • Causes gas gangrene
  • Can lead to shock and renal failure

Question 3

Reduction

Answer 3

• Principles
  
  • Displaced fractures should be reduced
  • Aim for anatomical reduction
  • Alignment more important than position
• Methods
  
  • Manipulation/closed reduction
    
    • Under local, regional or GA
    • Traction to disimpact
    • Manipulation to align
  • Open reduction (and internal fixation)
    
    • Accurate reduction vs risks of surgery
    • Intra articular and open fractures
    • Two fractures to one limb
    • Failed conservative management
    • Bilateral identical fractures

Question 4

Restriction

Answer 4

• Principles
  
  • Interfragmentary strain hypothesis dictates that issue formed at fracture site depends n strain
  • Fixation causes less strain, less pain and increased stability
• Methods
  
  • Non-rigid
    
    • Slings
    • Elastic supports
  • Plaster
    
    • POP
    • In first 24-48hrs use back slab or splint case due to risk of compartment syndrome
  • Functional bracing
    
    • Joints free to move but bone shafts supported
  • Continuous traction
    
    • Collar and cuff
  • Ex-Fix
    
    • Fragments held in position by pins/wires which are then connected to an external frame
    • Used to open fractures, burns, tissue loss to allow wound access
  • Risk of pin-site infections
• Internal fixation
  
  • Pins, plates, screws, IM nails
  • Usually perfect anatomical alignment
  • Increased stability
  • Aid early mobilisation

Question 5

Rehablitation

Answer 5

• Principles
  
  • Immobility reduces muscle and bone mass as well as joint stiffness
  • Need to maximise mobility of uninjured limbs
  • Quick return to function associated with lower morbidity
• Methods
  
  • PT
  • OT
  • Social services