Management of closed fracture Flashcards
Learning outcome:
- Grades of closed fracture
- Principles of treatment
- Aim of reduction
- Types of reduction
- Aim of fracture stabilization
- Methods of fracture stabilization
- Aim of rehabilitation
Grades of closed fracture?
Oestern and Tscherne Grading of Closed Fracture:
0- Simple fracture, no soft tissue injury
1- Fracture, superficial skin abrasion or skin bruising
2- Fracture, deep soft tissue contusion and swellinf
3- Fracture, marked soft tissue injury (threatened compartment syndrome)
Principles of closed fracture management?
- Resuscitation
- Reduction
- Fracture stabilization
- Rehabilitation
Aim of reduction?
Adequate apposition and normal alignment of bone fragments.
- Exception:
- Intra-articular fracture (requires anatomical reduction)
- Unnecessary if little or no displacement.
Types of reduction?
Based on method:
- Closed:
- CMR
- Mechanical Traction (if difficult to achieve due to muscls pull) - Open: Operative
i. Direct - manipulation of fracture fragments directly with hands of instruments
ii. Indirect - manipulation by applying corrective force at a distance from the fracture
(eg. ex-fix in comminuted articular fracture, reduce by ligamentotaxis or soft tissue taxis)
* ex-fix, distractor, forceps, retractor
Based on aim:
- Anatomical reduction
- aim: achieve absolute stability (restore anatomical morphology) - Functional reduction
- aim: achieve relative stability(restore length, angulation, rotational deformity)
Indication for closed reduction?
- Minimally displaced fracture
- Fracture in children
- Initial management for unstable fracture (allow easy surgical management later)
How to do CMR
- Adequate anaesthesia
- Muscle relaxant if needed
- Three-fold manouvre:
i. pull distal limb to disengage, exaggerate direction of original force
ii. reposition (oppose direction of original force)
iii. adjust alignment in each plane
* need at least 2 (one traction, one counter traction) - Confirmation
- palpation, intraoperative x-ray, image intensifier, arthroscopy
Indication for open reduction?
- Non-union
- Neurovascular compromise
- Intra-articular fracture
- Failed CMR
- Avulsion fracture
- Unstable fracture
Aim of fracture stabilization?
- To overcome muscle spasm and alleviate pain
- Ensure union takes place in good position
- Prevent further soft tissue injury
Stable vs unstable fracture?
A stable fracture is defined as a fracture that does not visibly displace under physiological load
eg:
- impacted fracture
- non displaced fracture
- green-stick fracture
- abduction fracture of proximal end of femoral neck
Methods of fracture stabilization?
Conservative:
- Splint
- Traction
- Cast
- Backslab
- Functional bracing
Operative:
- Absolute stabilizers
i. static compression
- compression plate
- lag screws
ii. dynamic compression
- tension band wires
- buttress plate
- Ilizarov circular external fixator - Relative stabilizers
i. locked
- external-fixator + schanz screws
- Intramedullary nailing
- bridging plate + locking head screws
ii. unlocked
- K-wires
- conservative
Principles of diaphyseal fracture management
- function of diaphysis:
* maintain proximal and distal joint in their correct spatial relationship
* provide muscle attachment - Aim of reduction: normal mechanical axis (functional)
* How? Restore:
I. length- up to 1cm acceptable in LL
- UL usually not a problem
II. angulation - tibia (anterior posterior limit 10 degree, valgus varus less than 5)
- humerus (30 degree limit)
III. rotational deformity - humerus (20 degree limit)
** all diaphysis okay for functional reduction except radius and ulna (fx as pruj, druj)
- Fixation
* Intramedullary nail (load sharing): transverse fracture only
* Interlocking nail (load bearing): multifragmentary fracture
* Plate: when shaft fracture extend to metaphysis or joint
- compression: transverse
- bridging: multifragmentary fracture
* External fixator:
- to allow wound care if (1) severe soft tissue problem, infection (2) polytrauma needing more important care (3) logistics/technical reason
- definitive treatment if pt could not afford, bt predisposed to pin-tract infection
Principles of articular fracture management
- Function: provide smooth, stable articulation between bones
- Aim of reduction: Restore anatomical morphology
* why anatomical?
- joint stability depends on passive stabilizers (bones, ligs) and active stabilizers (muscles across joint) -> joint instability
- defects in stabilizers (bone) can disrupt effective motion of joint and joint mechanics -> injury leads to arthrofibrosis within joint or osteoarthrosis - Fixation
* Impacted fracture
I. Clear haematoma or early callus, but retain all articular fragments
II. Traction/Distraction with external fixator to allow ligamentotaxis (indirect reduction) if needed
III. Deliver fragments with osteotome/elevator, temporary fix with K-wire
lV. Fill-in empty space with bone graft
V. Butress plate
* Simple fracture: lag screws, buttress plate
When to use splint
Fascilitates patient transportation and radiographic study at early presentation
What is cast splintage
Use of Plaster of Paris to hold reduction.
Plaster of Paris?
Calcium Sulphate Hydroxide + Water
-> Calcium Sulphate Dihydroxide + Heat
When to use cast
As definitive stabilizers in:
- stable fracture
- children fracture
- undisplaced fracture
- contraindications to surgery (no consent, confused or uncooperative pt)
Pros and cons of cast splintage
+ve
- Safe (provided pressure sores is prevented)
- Hold (Patient can bear weight on cast)
- Speed (not dependent on hospital, early discharge. speed of union is still the same)
- ve
1. Move (joints immovable, liable to stiffness) - can be minimzed by:
i. delayed splintage
ii. replace cast with brace later after limb can be handled without too much discomfort
Principles of cast application
- Three point fixation
- 1 pressure across fracture site
- 2 opposing pressure at intact soft tissue (acting ligamentotaxis) - Covers joint above and below fractured long bone
- Preserve other joint functions
- Adequate padding
Types of cast splintage
- Cylinder cast: mid thigh to above malleolus (sparing ankle joint)
- Long leg cast: mid thigh to distal MTT (sparing MTP joint)
3 Short leg/Boot cast: distal MTT to below knee (sparing knee, MTT joint)
- Long arm cast: distal MTC to below deltoid
- Hanging cast: “” + sling
Examples of cast uses
- Upper limb
i. Short arm cast: Hand/Wrist fracture
ii. Long arm, hanging cast: Forearm, elbow or distal humeral fracture
iii. Upper limb U Slab: Undisplaced humeral fracture
iv. Shoulder spica cast: Shoulder dislocation
v. Collar and cuff: Proximal humerus
- Lower limb
i. Short leg cast: foot, ankle, distal tibia or fibula fracture, CTEV
ii. Long leg cast: distal femur, knee, lower leg fracture, knee dislocation
iii. Unilateral hip spica: femur fracture, post-op hip dislocation
iv. Bilateral long leg hip spica: femur, acetabulum, pelvic fracture, post-op ORIF
v. Abduction boots: Post-op abductor release
Complication of cast splintage
- Vascular cx (tight POP)
- 5Ps (Pain, Pallor, Parasthesia, Paralysis, Pulseless) - Pressure sores
- burning pain
- recurrent swelling
- offensive smell
- discharge - Allergy Contact Dermatitis (Plaster allergy)
- Skin abrasion/laceration
- when attempt to remove cast by electric saw - Tight cast (early) due to leg edema
- compartment syndrome - Loose cast (displaced fracture)- TCA 1 week review cast)
Do’s and dont’s of cast splintage
Do’s
- allow plaster to dry on its own
- encourage joint movement (not in plaster)
- keep plaster dry
- weightbear as instructed
- report to doc at once when there are features of compartment syndrome, pressure sores
Dont’s
- do not stand on plaster for first 48 hours
- dont get it wet
What is traction
Act of exerting continuous pull in long axis of the bone to counter the deforming force
Function of traction
Function:
- To overcome muscle spasm (eg. shaft fractures are easily displaced by spasm)
- To relieve pain
Quartet Features -ve 1. Cannot hold fracture still 2. Keeps patient in hospital (need to be replaced later with bracing) \+ve 1. Safe if not excessive 2. Patient can move and exercise
Types of traction
Types of traction:
- Skin Traction
- Skeletal Traction
Methods of traction:
- Fixed traction
- Balance traction
- Combined traction
Types of skin traction
- Adhesive
- for young
- grip is more secure
- need to shave first, apply benzoin - Non- adhesive
- for elderly
- skin more fragile (atrophy), prone to abrasion
- grip is less secure
Indication and contraindication to skin traction
Indication:
- Weight required not more than 5kg
- Short duration use (eg. OT in 3 days)
Contraindication:
- Skin abrasion at area of applied traction
- Skin laceration at area of applied traction
- Skin infection at area of applied traction
- Allergy to plaster
- Circulation impared: impending gangrene, varicose ulcers
- Marked shortening
Examples of skin traction
Upper Limb
- Dunlop’s Traction: Gravity traction for supracondylar fracture in children
Lower Limb
- Bryant’s Traction: Gravity traction for shart of femur fracture in children up to 2 yo, less than 12.5 kg
- Buck’s Traction: Balanced traction
- indication:
i. neck of femur fracture
ii. shaft of femur fracture
iii. undisplaced fracture of acetabulum
iv. post-reduction of dislocated hip
v. to relieve low back pain?
Proper application of skin traction
- String taut
- Weight do not rest on ground
- Skin surrounding not wrinkled (indicates too tight)
- Not on bony prominence. If needed, use padding (eg. gamgee)
- Loop projecting below at least 5cm (allow toe, ankle movement)
Indication and contraindications of skeletal traction
- Weight required is more than 5kg (maximum is 10% of pt weight)
- Skin traction is not possible (contraindicated)
- For long duration (eg. OT in 2-3 weeks)
Contraindication
- Children
- growth plates
- weight
Common sites for skeletal traction
Upper Limb
- 3cm distal to tip of olecranon
- 2cm proximal to distal end of metacarpal
Lower Limb
- Femoral supracondyle
- Tibia tubercle (2cm below and behind)*from lateral to medial (avoid common peroneal nerve)
- Calcaneum (2cm below, behind lateral malleolar)*tip of calcaneum, two finger above and lateral. insert medial to lateral
6 Indication of internal fixation
- Irreducible fracture except by operation (eg. femur fracture)
- Unstable fracture
- Fracture that unites poorly and slowly
- neck of femur fracture - Pathological fracture (bone disease prevent healing)
- Multiple fractures needing early fixation (prevent general complication)
- Fracture in patients present nursing difficulties
- paraplegic
- very eldery patient
- multiple injury (eg. bilateral limb fracture)
6 Complication of skeletal traction
- Pin tract infection (due to loosening of pins)
- Osteomyelitis
- Distraction of fracture (large force applied)
- Ligament damage
- Epiphyseal growth plate damage in children
- DVT (immobility)
- Nerve injury (peroneal nerve-foot drop)
Indication for external fixation
Temporary
- to allow wound care if :
(1) severe soft tissue problem, infection
(2) polytrauma needing more important care
(3) logistics/technical reason
Definitive
- if pt could not afford, bt predisposed to pin-tract infection
Complication of external fixation
- Pin track infection: Lytic lesion surrounding shantz pin
- Osteomyelitis:
- Overdistraction: Non-union
- Damage to soft tissue structures (vascular and nerve)
Increase stability of external fixator
- Distance between rods and bone axis lower
- Number of shanz screws, rods
- Spacing between shanz screws
- Number of planes
- Proximity between shanz screws and fracture site at least 5cm
Aim of rehabilitation
- Reduce swelling/edema
- active exercise as tolerable
- elevate limb
- assisted movement if cannot - Preserve joint movement
- Restore muscle strength
