Orthopaedics unit 5 Common fractures - deck 3 Flashcards
What is the essential strategy of long-term fracture management
To return the injured person to their pre-injury level of function by the safest means possible.
What are the 3 main factors which will determine the tactics used to achieve the aim of long-term fracture management ‘‘to return the injured person to their pre-injury level of function by the safest means possible.’’
- The injured person
- The injury
- The surgeon.
Define what is meant by the term ‘definitive management’
This is defined as the technique used (after bleeding and pain have been controlled) to restore normal function to the injured part of the body (usually a limb), after a fracture
What are the main factors which determine the functional requirements of the individual and what you need to aim to achieve in terms of restoring function for that individual ?
- Age
- Physical health
- Occupation
Describe why in older individuals the clinician may opt for a less than perfect result in the management of their fracture, as long as it doesn’t affect their daily acitivities
Older people may have poor bone quality due to osteoporosis, and may have medical problems such as heart disease or diabetes. The benefit must outwiegh the risk when providing treatment and in some of these scenarios the benefit to these individuals may not out-weigh the risk ==> opting for a less than perfect management strategy
e.g. how fractures of the wrist are treated in the elderly. The fracture may be treated under local anaesthesia in A&E. Although this might not achieve the perfect result, the injured person can then be discharged home to an environment where they may function satisfactorily without further extensive treatment, which could lead to unnecessary complications such as bedsores, pneumonia or urinary infections.
Why may on the other hand a young fit, right-handed craftsman or woman who injures his/her right wrist joint may be prepared to spend many months undergoing treatment to ensure a perfect result?
Because that is what is required for his/her long-term health and employment security.
What is the key thing to remember when deciding on a treatment strategy ?
The benefits must out-weigh the risks
Appreciate this:
A young and well person will tolerate long-term treatment and surgery with no physical detriment, but in the older patient, perfect function may sometimes only be achieved at the expense of the risk of complications.
When managing someones injury what should not be underestimated ?
They psychological effects caused by the injury
In order to achieve acceptable function following a fraction, what must be done ?
The anatomy of a fracture should be returned to as near normal as is safely and practically possible
What is the difference in margin for error for restoring the normal anatomy of a fracture which passes into a joint compared to a fracture which occurs through the shaft of a long-bone?
- If a fracture passes into a joint then the anatomy needs to be restored very accurately to normal in order to achieve acceptable function
- Whereas if a fracture occurs in the shaft of a long bone then the margin for error is much greater and something less than perfect is acceptable
Is it possible to achieve restoration of normal function in all fractures ?
No some injuries are so severe that normal restoration is impossible.
How is restoration of a fracture to a normal position is achieved?
Reduction:
The fracture must be reduced to the normal position and then held there until the bone heals naturally.
How is closed reduction of a fracture achieved ?
By traction on the distal fragment and then a relocation of that distal part back onto the proximal fragment by manipulation
What is necessary to ensure the patient is provided in order to achieve a reduction of a fracture ?
Adequate analgesia - general or regional anaesthesia may be used.
What does manipulation of the distal part of the fracture usually involve ?
Usually involves reversing the direction of the deforming force
If closed reduction of a fracture is unsuccessful what can be done to reduce the fracture?
Open reduction - the fracture site is opened surgically and the fragments are relocated directly under vision.
What must be done once a fracture has be adequately realigned via reduction ?
It must be held in the desired position until the bone has become strong enough to support itself (united) and then protected until it is strong enough to bear some load (consolidated).
What are the 4 main ways in which a fracture can be held in place and describe them
- Casting - surrounding the broken limb with a hard ‘coat’ which holds the fracture steady.
- Internal fixation - holding broken bones together using screws and plates inside the body.
- External fixation - an external ‘bar’ outside the body attached to pins sited in the broken bones.
- Traction - pulling on a broken limb to align the bones.
Once the fracture is manipulated, the holding exercise may simply involve placing the limb in a plaster of Paris cast until when?
Union
What 2 things must a cast ensure correct healing of a fracture ?
Fracture must be held in the correct position by the cast and it must be maintained at the proper length
If a cast holds the fracture fragments too far away from each other what may happen?
Delayed union of the fragments
In order to ensure complete control of all dimensions of the fracture the cast must what?
Immobilise the joints above and below the fracture site, as joint movement may result in distortion in one or more dimensions.
How does a cast work?
A cast acts as a splint.
By controlling joint movement and position it may be used to control posture. The plaster cast is moulded so that the pressure is exerted at three points, holding the fractured bone in the correct position until it has healed.
What are the main disadvantages of casts ?
- They are heavy and they immobilise the joints.
- Clinicians cannot examine the covered part, or use investigative techniques such as Xray
- Cost and inconvenience in having to remove them during treatment to assess progress
- The immobility imposed on a limb results in muscle wasting and limited mobility due to joint stiffness.
What can be used to overcome the disadvantages of regular plaster cast ?
By freeing the joints and using functional braces
In order to maintain three-dimensional control of the fracture when using a functional brace what is it necessary to do?
It is necessary to support the cast at the joints by a combination of accurate moulding and the provision of hinges
What directions of motion are usually permitted by the hinges in a functional cast brace?
Motion in one direction, usually flexion and extension.
Why do functional cast braces tend to be used after a few weeks ?
Because they are highly dependent on a very accurate fit, so used when pain and swelling have settled
Why were new materials developed for making casts
Because Plaster of Paris is relatively brittle, is messy and is very difficult to apply well. It is heavy and awkward particularly for an elderly person and, as it takes up to three days to dry, it can be very inconvenient.
For these reasons stronger and lighter new materials have been developed.
What are the new materials used for casts ?
Glass fibre and polyurethane resin combinations.
When are the new materials used for casts and why?
They are used used as secondary casts a week or two after the injury, once swelling has settled. Because they are not as versatile as the Plaster of Paris casts
What are the new materials for casts ideal for making ?
Cast braces (functional cast braces)
Injury to what are high energy fractures often associated with ?
Extensive soft-tissue damage, which often results in breaching of the skin or even loss of soft tissue.
In terms of healing what is it important to initially have for high energy fractures which has caused extensive soft-tissue damage
Because the blood supply is severely damaged, it is important to have an initial phase of soft tissue healing
Why are plaster splints and internal fixation highly unsuitable for high-energy fractures with extensive soft-tissue damage ?
Plaster splints are highly unsuitable because the wounds become inaccessible.
Internal fixation is hazardous because of ischaemia (lack of blood), and wound contamination increases the risk of an infection being introduced during surgery.
Define ischaemia
This is the lack of blood supply to an organ or part of the body
What device can be used to allow an initial phase of soft tissue healing in high-energy fractures with extensive soft tissue damage?
External fixators
Describe what an external fixator is and how it works
It is a device which is fixed to the bones by pins and which stabilises the limb by means of an external scaffold
It provides stability of the bones and allows access to the soft tissues for dressings and secondary surgery such as skin grafting.
When were external fixators initially designed to be removed ?
Once the soft tissues healed, fracture treatment continued by other means
Is it possible now to once the soft tissues have healed to definitively treat the fracture with an external fixator ?
Yes - particularly if the fixator can be adjusted in the later stages to permit some movement (dynamisation) at the fracture site.
What is the main problem associated with external fixators ?
Infection - the pin sites which are an easy route for infection
When is internal fixation used in the treatment of fractures ?
Where a high degree of accuracy is required, or other methods fail
What does internal fixation of a fracture involve
This involves the holding of the fractured bone with devices such as screws, nails or plates.
Why arent all fractures treated using internal fixation ?
- It is very technically demanding
- Has many complications
- It prevents natural healing.
What are the 4 main ways in which internal fixation of a fracture can be achieved ?
- Apposition.
- Interfragmentary compression.
- Interfragmentary compression plus onlay device.
- Inlay device.
Define what apposition means
Together in aligement
If internal fixation is to be used once a fracture has been realigned what may the fragments only need to be held in for satisfactory healing?
They may only need to be held apposition (together in alignment)
When internal fixation is to be used who often only needs a fracture to be held in apposition for satisfactory healing to occur ?
Children
What device can apposition of a fracture be achieved with?
By using semi-flexible wires known as K or Kirschner wires
How do k-wires work?
They hold position without producing immobility and so healing occurs by natural callus formation.
They can be left standing proud of the bone and so can easily be pulled out once union is established and before consolidation.
