Principles of Fracture Management Flashcards
Goals of fracture management?
- Achieve bony union in a satisfactory position
- Facilitate the restoration of function
The 4R’s of fracture management?
- RECOGNISE
- REDUCE
- RETAIN
- REHABILITATE
What is to recognise?
rescucitation - ABCDE
What is to reduce?
is a surgical procedure to repair a fracture or dislocation to the correct alignment
- for closed and open fractures
What is to retain?
- non surgical
- POP
- traction - Surgical
- Internal fixation
- External fixation
What is rehabilitation?
physiotherapy
Choice of fracture management depends on?
- Available skills
- Available resources
- Patient factors
- Fracture factors
Conservative treatment vs available treatment?
- Conservative treatment usually requires less skill to perform than surgical treatment
- However, it usually necessitates closer and more frequent monitoring - Conservative treatment is much less expensive and requires less theatre time
- Surgical treatment requires more theatre time and the equipment is specialised and expensive
What patient patient factors contribute to choice of method in fracture management?
- General
- Age
- Co morbidity
- Ability to pay! - Specific
- Polytrauma/multiple fractures
- Stability of patient condition
Fracture factors that contribute to choice of treatment method?
- Open or closed fracture
- Simple or comminuted
- Intra articular fractures
- Special cases eg neck of femur, talus
- Multiple fractures, particularly in one limb
- Neurovascular injury
What is POP treatment?
plaster of paris
- quick setting gypsum plaster consisting of a fine white powder (calcium sulfate hemihydrate) which hardens when moistened and allowed to dry
What is POP treatment for?
closed reduction
Application of POP?
- Joint above and below fracture
- Whilst still wet the POP is moulded to press and hold the fracture in a reduced position
- As the swelling decreases the POP may become loose and need to be changed
- Removal of POP once fracture is well consolidated and start exercises to restore function
Steps in POP application?
- examine the limb
- position the limb in the correct position for splinting
- use stockinette to cover the skin of the affected limb
- wrap cotton wool padding starting distally going proximally and overlapeach layer by 50%
- soak plaster in water until bubbles cease to rise remove from the water and gently swueeze the excess water
- overlap each layer by 50% and smooth the p[laster with your palm
- ensure joint immobilization
- repeat examination
- radiography
- patient education
Pros of POP?
- Cheap and simple
- Successful in many fractures
- Avoids the risks of surgery
Cons of POP?
- Joint immobilisation causing stiffness and muscle wasting
- Doesn’t always result in adequate reduction
- Requires close monitoring, fracture can re-displace
What is traction?
- Applying weights to the limb distal to the level of the fracture to reduce and then immobilise the fracture
- Can be skin traction or skeletal traction
- Counter traction is provided by the weight of the patient
What is skin traction?
applied by strapping the patients affected lower limb and attaching weights
Describe skin traction?
- Children, to avoid risk of pin and growth plates
- Used for initial splintage
- Can tolerate less weight
What is skeletal traction?
a pin is placed inside your bone
Describe skeletal traction?
- Adults
- More weight
- Can stay for longer
When do we use traction?
- Femur fractures
- Distal humerus fractures
- Occasionally in tibial fractures
What is internal fixation?
the surgical implementation of implants for the purpose of repairing a bone - physically reconnects bone
Pros of internal fixation?
- Can achieve more accurate reduction
- Can achieve better control of reduction
- Allows earlier return to function
- Decreases joint stiffness and muscle weakness
Cons of internal fixation?
- Risks of surgery / infection
- Cost/resources
What is ORIF?
open reduction internal fixation
open reduction = a surgeon makes an incision to re-align bone
internal fixation = bones are held together with hardware
Note: used in serious fractures that cant be treated with cast or splint
Indications for ORIF?
- Comminuted fractures
- Multiple fractures / multiple limbs
- Polytrauma
- Articular fractures
- Special fractures
- Vascular injuries
- Malunion / nonunion (failed conservative treatment)
What is external fixation?
- Insertion of percutaneous pins or wires into bone
- Attachment of external frame to pins
Types of external fixators?
- Hoffman 1
- Hoffman 2
- Orthofix
- Lizarov
Indications for external fixation?
- Severe open fractures
- Polytrauma / rapid stabilisation
- Reconstruction
- Bone transport
- Leg lengthening
- Deformity correction - broken bone accompanied by significant swelling, bone loss or soft tissue loss
Pros of external fixation?
- Usually easier and quicker to apply
- Pins away from wound / fracture
- Can do secondary reduction
- Still allows joint movement / weight bearing
- Good access to wounds
Cons of external fixation?
- External, bulky
- Pin sites
- Tethering of muscles
- Higher non union rate
Complications of POP?
- Tightness / compartment syndrome
- Pressure sores
- Loss of reduction
- Joint stiffness / muscle wasting
Complications of traction?
- Pin site infection
- Malunion
- Joint stiffness / muscle wasting
Complications of internal fixation?
- Infection
- Implant failure
Complications of external fixation?
- Neurovascular injury on insertion
- Pin site infection
- Non / mal union
- Joint stiffness
