Principles of Fracture Mgmt Flashcards
What is a fracture?
Soft tissue injury with a disruption in the continuity of a bone
What is an open fracture?
- Direct communication between fracture site + external environment
- Often through skin, but open pelvic fractures can be through vagina or rectum
- Commonly → tibial, phalangeal, forarm, ankle + metacarpal
- Much higher risk than closed for infection
- Assess potential for associated soft tissue damage → neurovascular damage / muscle bulk damage / compartment syndrome
In contrast, a closed fracture is one where the bone breaks but there is no puncture or open wound in the skin
Fractures can be described according to the bone involved (may be multiple) and also the position (proximal, middle, distal).
Which different pattern types exist for fractures?
- Greenstick most common in children
How can you describe the extent of deformity for fractures?
- Displacement → % loss of end-to-end contact of distal + proximal bone ends; displacement can be minimal or significant
- Shortening → if shortening occurred + to what extent (cm)
- Angulation → of distal to proximal pole (degrees)
- Rotation → rotation O/E and on XR (degrees)
Which other associations may be described for fractures?
- Involvement of the joint (intra- or extra-articular)
- Associated dislocation (a fracture-dislocation)
- If in a long bone, epiphysis, diaphysis or metaphysis
- Soft tissue associations must also be described (muscle, blood vessels, nerves)
Example of fracture description
This is a closed fracture of the left femoral shaft. It affects the middle third and is a spiral fracture. The distal pole is displaced by 50%, is rotated by 30 degrees, is shortened by 1cm and clinically the limb is externally rotated. There is no intra-articular involvement, no associated dislocation and no soft tissue complications
Which factors impact on the rate at which fractures heal?
- The patient → age + adverse health factors
- The fracture → closed heal faster than diaphyseal
- The treatment → good blood supply + immobilisation
On avg, # of lower limbs take 6wks in children and 12 wks in adults to heal; and those of upper limbs take 3 and 6 weeks.
What are the rule of 2s, that plain radiographs follow?
- 2 views → AP + lateral: to assess displacement
- 2 joints → above + below: to identify joint extension
- 2 times → one film prereduction + one film postreduction: to assess effectiveness of reduction
- 2 sides → to compare normal + abnormal
How do you interpret an orthopaedic radiograph?
ABCS system
- Adequacy + alignment → should include joint above and below to identify fully the features of the injury, including alignment of bones with each other
- Bone margin + density → followed to note any disruption indicating fractures; fracture pattern and deformity should be noted as the radiographs examined closely for other fractures in other bones
- Cartilage + joint → widening/disruption of joint spaces and surfaces may indicate intra-articular involvement or dislocation, which may alter management
- Soft tissues → air in tissues may indicate open wound, fracture, visceral injury or synergistic infection; gross swelling of soft tissues may produce local complications
What is the initial mangement for a fracture?
- ABCDE
- Compartment syndrome recognised early
- Open fracture initial assessment
- Neurovascular compromise assessment → examine distal limb; rapid reduction of fracture may be needed to save limb from ischaemia
How should open fractures be managed initially?
Prevent infection
- Wound swab + photographed
- Cover with abx dressings + temp splint
- Tetanus prophylaxis
- IV Abx
What are the 3 principles of fracture management?
Reduction → immobilisation → rehabilitation
Reduction involves restoring the anatomical alignment of a fracture or dislocation of the deformed limb. The main principle in any reduction, regardless of the method employed, is to correct the deforming forces that resulted in the injury.
What is the difference between closed and open reduction?
- Closed → by traction or manipulation under anaesthesia
- Open → with internal fixation (ORIF): fracture manually reduced and then internally fixed; typically this is used when displacement is too severe for closed reduction
What are the clinical requirements of reduction?
- Analgesia (regional or local blockade)
- Conscious sedation
- 3 people for maneouvre → one to perform reduction + one to provide countertraction, third to apply plaster
Which fractures don’t need to be reduced?
- Mid-clavicle (uncomplicated)
- Ribs
- Scapular blade
- Pubic ramus
These don’t need to be reduced even if displaced, as the functional outcome is the same
In order for the fracture to heal, the two ends of bone must be immobilised (fixation) in place. Fractures can be fixed either externally or internally (where the fracture is also reduced).
How is non-operative immobilisation achieved?
- Splints → relieves pain + prevents further damage
- Sling / Collar + cuff → for mid-clavicular fractures
- Casts → plaster of paris, backslab
- Traction → gravity, skin traction, skeletal traction
- Cast bracing → plaster cast on thigh + calf joined by a brace
Operative immobilisation is achieved by internal or external fixation.
What is external fixation?
- Approach good for complex open fractures
- Screws drilled into the bones + held in place externally
- Ring fixators suitable for complicated fractures (eg. comminuted tibial fractures) where bones held firmly in place from multiple directions
What is internal fixation?
Follows open reduction in ORIF, uses:
- Plates + screws → suitable for articular + comminuted long-bone fractures (eg ankle fractures)
- Intramedullary nails → for fractures of long bones (femur, tibia, humerus) as it allows early mobilisation
- Kirschner (K) wires → commonly used for foot, wrist and hand fractures; wires are inserted percutaneously and can be placed under tension
What are the aims of rehabilitation?
- Physiotherapy crucial to allow other joints to remain mobile + regain muscle tone
- Ensures good joint alignment and maximise joint function once the fracture has healed
- A fracture is united when clinically there is absence of pain, tenderness or swelling and also radiologically there is new bone visible on XR
What are the 3 stages of bone healing?
- Inflammatory phase → occurs in first 24-72hrs; bleeding immediately after fracture causes swelling + cytokines; stimulates rest of repair mechanism
-
Reparative phase → repair of fractured bone depends on stability of fracture:
- healing by callus in unstable fractures: occurs between 4-8wks; necrotic bone resorbed + weak woven bone laid down, which is precursor for highly organised + very strong lamellar bone
- healing by primary bone healing in stable fractures: contact healing can occur when 2 ends are in direct contact + ‘cutting cones’ cross the fracture
- Remodelling phase → starts 8-12wks after fracture, at the end of the repair phase + continues for years; strong lamellar bone replaces woven bone
