Principles of Fracture Management

Question 1

Most important principles.

Answer 1

Reduce

Hold

Rehabilitate

Question 2

What is done before RHR in high-energy injuries?

Answer 2

Resuscitation following ATLS principles

Question 3

What is reduction?

Answer 3

Restoring the anatomical alignment of a fracture or dislocation of the deformed limb

Question 4

Why is reduction important?

Answer 4

Tamponade of bleeding at fracture site

Reduction in the traction of surrounding soft tissues

Reduction in the traction on the traversing nerves

Reduction of pressure on traversing blood vessels

Question 5

How is fracture reduction typically done?

Answer 5

Performed closed in the emergency setting.

Some need open reduction by directly visualising the fracture or intra-operatively.

Question 6

What does reduction require?

Answer 6

Analgesia either regional or local blockade
E.g. fascia iliaca blockade.

Patients usually require a short period of conscious sedation as well, provided A&E has access to anaesthetic agents, airway adjuncts and monitoring.

Specific manoeuvres usually requires two people

Usually also requires a third person to apply the plaster

Question 7

What does hold involve?

Answer 7

Immobilising a fracture, this also involves traction if required (especially where the muscular pull across the fracture site is strong and makes the fracture unstable).

Question 8

Most common way to immobilise a fracture

Answer 8

Simple splints or plaster casts.

Question 9

Most important principles when applying a plaster cast.

Answer 9

First 2 weeks plasters are not circumferential
This is to allow the fracture to swell.

If there is axial instability the plaster should cross both the joint above and below

Usually termed as “above knee” or “above elbow”

Question 10

Clinical requirements of immobilisation.

Answer 10

Can the patient bear weight? -> Let them know

Do they need thromboprophylaxis? -> If immobilised higher risk of DVT

Have you provided advice about symptoms of compartment syndrome and how to recognise it?

Question 11

Explain rehabilitation

Answer 11

Intensive physiotherapy following fracture management.

Essential to successful recovery and is important to ensure patient to move non-immobilised unaffected joints from the outset.

Be mindful that immobility and inability to weight bear can have a profound effect on ability to cope at home.

Occupational therapist needs to be involved here.