Fracture management Flashcards
What does fracture treatment depend on? (3)
Stability of the fracture
Patient factors (fitness, other injuries etc)
Closed vs open
Which type of fracture is completely stable?
Transverse fracture
How would you define an open fracture?
A fracture is said to be ‘open’ if there is a direct communication between the external environment and the fracture.
This is usually through a break in the skin, but not always! i.e a fractured pelvis can penetrate through the rectum
In which 2 main ways do open fractures differ from closed fractures?
Higher risk of infection
Higher energy of injury
What is the Gustilo grading system?
A grading tool used to guide management of compound fractures, with higher grade injuries associated with higher risk of complications.
Describe the Gustilo grading of open fractures
Type 1 - low energy, smaller wound (<1cm)
Type 2 - moderate soft tissue damage, wound 1-10cm
Type 3 - high energy, wound >10cm; any gunshot, farm accident. Type 3 is split into 3a, 3b and 3c (more severe injury)
How are open fractures managed initially?
Give the patient tetanus (if not covered) and antibiotic prophylaxis - to prevent/slow down bacterial growth + pain relief
Photograph the wound so that it can be sent to surgeons/plastic surgeons so that they can start to plan treatment.
Cover the wound and stabilise the limb (prevent bone movement and further soft tissue damage or pain)
Open fractures are regarded as a surgical emergency - all operations within 24hrs but some in 6hrs if they are highly contaminated etc
Management of fractures during/after surgery
Early and thorough wound excision and toilet by senior experienced surgeons (flush/wash out the wound)
Wound is left open and this allows for a wound review - check if there is any more dead material and if so it is washed out again
Early definitive skin cover (5-7 days)
Stabilise the fracture
What is involved in the clinical assessment of a patient with a fracture?
Examine the fracture
Circulation
Neurological assessment
Open vs closed
Once a fracture is back in its required position (i.e reduced back to normal anatomical alignment) this position needs to be maintained.
How can this be maintained?
Conservative treatment
Operative treatment
Give examples of conservative fracture treatment
If no initial immobilisation or reduction required they may need no support at all or they may require support i.e Strapping or a Brace
If initial immobilisation is required then:-
Cast
Functional bracing
Traction
Give examples of operative fracture treatment
Pins
External fixators
Internal fixation:- Intra-medullary rods, screws and plates
What 3 principles of casts maintain the alignment of bone?
Three point loading
Hydraulics by using functional bracing
Rotational control
- By including joint above and below
Describe three point loading
A fracture can be reduced back by applying force at either end of the bone – the bone bends back into position
Above the fracture there will always be a bit of intact soft tissue (the soft tissue hinge) which acts like a spring and helps maintain the alignment of the bone.
Functional bracing
Used mainly for long bones i.e femur, tibia + humerus
The joint is left free to mobilise (prevents stiffness)
This is what caitlin’s mum had after her cast
Types of traction
Skin traction
Skeletal traction
Describe skeletal traction
The application of a pulling force directly to the bone. This provides a strong, continual axial pull.
Tightens up the soft tissue sleeve
Restores the alignment of the bone
Allows greater force/weight
If left on it maintains the reduction i.e maintains position
Describe skin traction
Direct application of a pulling force on the patient’s skin via adhesive or non-adhesive tape
Its use depends on weight - can’t be used on a child under 12 kg
Risks of skin traction
Blistering/sloughing
Compartment syndrome - due to elevation and compression
What is external fixation?
Fixing the bone from the outside
Can use pins or wires which pass through the skin and bone and attach them on to an external frame
Apply force/pull to realign the bone
What are common indications for external fixation?
Fractures with poor soft tissue conditions
Where distraction through the fixator may help with fragment reduction
Emergency pelvic stabilisation for haemorrhage control
Limb reconstruction
Types of fixators used
Unilateral (runs down one side of the bone)
Multilateral
Circular
Complications in external fixation
Neurovascular injury - wires may hit nerve etc
Pin tract infection - organisms from skin through tract
Loss of fracture alignment as soft tissue stretch is lost
Intra-medullary nailing
Commonly used for long bone fractures (tibia, humerus, femur)
Pass nail down centre of long bone - this is x-ray guided.
The bone is locked onto the nail and so it can’t move, shorten or rotate around the nail
Advantages of intra-medullary nailing
Incisions remote from fracture - less chance of contamination
Joints free to move
Minimal fracture exposure - Preserve periosteum and avoid necrosis /damage soft tissues + bone
Internal fixation
Usually have to make a hole over the fracture and expose it. This gives access for bone grafting - put bone in to accelerate union.
The advantage of fixing bones rather than treating them conservatively is that it allows for early joint mobilisation
Risk of internal fixation
Devascularisation - opening up the fracture cuts out it’s blood supply - may be slow to heal
Wound problems
Infection
What are the 2 different types of screws?
Cortical screws - able to get through hard cortical bone
Cancellous screws
Types of plates
Compression plates - squeeze bone together
Neutralisation - resists rotating forces
Buttress - stop collapse
Strut/bridging
- No opening fracture - more like external nail
Where are plates fixed?
On the outside of bone
