general principles of FRACTURE management.pptx

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general principles of FRACTURE management.ppt

1. GENERAL PRINCIPLES OF MANAGEMENT OF FRACTURES AIM: “ Restoration of the limb to be functionally and anatomically indistinguishable from the normal.” PRINCIPLES OF MANAGEMENT :- I . EFFICIENT FIRST AID: --- RTA- poly trauma Goals of first aid :-- (3 p’s ) a) Preserve life by carrying out appropriate. resuscitative measures b) Prevent further injuries by careful handling. c) Promote recovery

2. Initial care of the injured : a) at the scene of accident :- inform police and ambulance * check vital parameters quickly --pulse, Bp, level of consciousness Mc Murthy has laid down the A to F management guidelines to be followed in the institutional care of the injured in the order of importance . 1.Airway management 2.Blood and fluid replacement 3. CNS management 4.Digestive system management 5.Excretory system management 6.Fracture management

3. AIRWAY Clean the mouth of clots, dentures, loose teeth etc, Extend the neck slightly as this opens up the pharynx, If patient is not breathing, begin artificial respiration . Close the nostrils, give mouth to mouth respiration . Blow at the rate of 16/min and see for chest raise. Mouth to nose respiration is carried out if there is extensive injury to the mouth.

4. Cardiac: Examine radial pulse and carotid pulse for the function of cardia . if the pulse is absent : perform external cardiac massage at a rate of 72 /min. it is preferable to carryout both external cardiac massage and artificial respiration simultaneously by two persons trained in first aid. If one person is there then first artificial respiration is given once and then the same person should quickly change position and carryout external cardiac massage five times: so this 1:5 ratio should be maintained throughout. CPR should be carried out until the patient recovers or at least for half an hour.

5. BLEEDING : Arrest the bleeding by elevation or direct application of pressure over the bleeding points. Hypovolemic shock – treatment with fluid and blood replacement. EXAMINE THE VITAL STRUCTURES: HEAD INJURY : Pupils Level of consciousness Neurological deficit Cover the skull injuries with a clean cloth

6. CHEST INJURIES: Tension pneumothorax ABDOMINAL INJURIES : Abdominal rigidity suggests blunt injury abdomen / damage to liver, spleen , colon etc.. emergency PELVIS FRACTURES : Compression and distraction test positive. INJURIES TO GENITOURINARY SYSTEM : Suprapubic swelling , fullness or tenderness indicates bladder injury. injury to scrotum or perineal hematoma indicates urethral rupture.

7. SPINE INJURIES : Suspect c- spine injury if the patient is lying still and loathes turning the neck . In paraplegic patient suspect thoracic or dorsal spine injury.

8. FRACTURES : Deformity , pain , swelling, loss of function of limb suggestive of fracture. Fracture needs to be splinted with whatever material is available at the scene of accident. -- sling for clavicle fracture , shoulder fractures etc.. -- strap for clavicle fracture and rib fractures. -- thomas splint for lower limb fractures. Remember: shock is to be corrected first Systemic injuries to be tackled next Spine injuries call for extreme caution II) SAFE TRANSPORT

9. MANAGEMENT AT THE HOSPITAL : MC MURTHY – A to F management guidelines start iv fluids – same time send basic blood investigations like CBP , CT, BT , TLC , Other emergency measures like – administration of antitoxin , antibiotics, anti gas gangrene serum and wound debridement should be carried out . ASD’s to be done . assessment of the local condition of the injured limb regarding complications like vascular injury, nerve injury etc.. Improve the general condition of the patient. Then Investigations --Radiographs of the part.

10. MANAGEMENT OF FRACTURES : Diagnosis of fractures : includes a) presence of fracture and its site b) nature of fracture – traumatic , pathological fractures , recent or old fractures and presence of complications. History : - Mode of injury , Nature of violence – direct or indirect. c /o pain --inability to use the limb . swelling

11. Signs : deformity ; eg .. dinner fork deformity in colles fracture. local tenderness crepitus Abnormal mobility Movements Measurements Radiological examination :--includes joint above and below. anteroposterior view , lateral view special view for some fractures.

12. MANAGEMENT OF FRACTURES I ) REDUCTION II) IMMOBILISATION TILL FRACTURE UNITES III) PHYSIOTHERAPHY IV) REHABILITATION I) REDUCTION METHODS : Closed reduction of the fracture by manipulation Open reduction II) IMMOBILISATION OR MAINTENANCE OF REDUCTION TILL FRACTURE UNITES : a) conservative : i ) POP casts ii) continuous traction –1)skin traction –fixed and balanced 2) skeletal traction –fixed and balanced iii) splints – thomas splint . b) Operative : i ) internal fixation ii) external fixation

13. REDUCTION : Not all fractures need reduction.. Eg .. Incomplete fracture without angulation Undisplaced fractures All displaced fractures needs reduction -- Angulated fractures -- Anterior , posterior , medial or lateral displacements to be corrected. -- Overriding needs correction to prevent limbs length discrepancy . Before reducing a fracture one should understand the mechanism of violence caused the fracture, the anatomical importance of the fracture site and displacements of the fracture fragments . eg .. colles fracture . Methods of reduction : i ) closed manipulation eg .. Colles fracture ii) open reduction– surgically open the fracture site and reduce fracture under vision .

14. IMMOBILISATION : Till fracture union is complete POP : - Hemihydrated calcium sulphate -- Initially plaster slabs applied. -- Once fracture edema is decreased plaster casts are applied. The patient or the parent should be instructed to report immediately if the fingers develop circulatory insufficiency like edema, pallor , cyanosis with increasing pain. Types of plaster casts : a) above elbow – fracture BB forearm b) below elbow – colles fracture c) U slab -- fracture humerus d) below knee – malleolar fractures e) above knee – BB leg fractures f) cylinder slab – fracture patella g) hip spica -fracture shaft femur One joint above one joint below fracture site should be immobilized. But fractures near the joint need one joint immobilization.

15. All joints which are not immobilised should be actively exercised to prevent stiffness . This also keeps the muscle inside the plaster in good tone and minimises wasting Check radiograph must always be taken after reduction to confirm the reduction. The plaster usually gets loose after 2 wks, partly due to the subsidence of swelling and partly due to the wasting of muscles under the plaster. Such a plaster must be removed and reapplied in close fitting manner to prevent angulation . Duration of Immobilisation : Children –upper limbs – 3to 4 wks --lower limbs – 6 to 8 wks Adults –upper limbs –6 to 8 wks --lower limbs –12 to 16 wks.

16. Diagnosis of Union of fracture : -- The absence of localized bony tenderness and abnormal mobility. -- Radiographs taken to confirm union After clinical union : upper limbs – i ) Plaster discarded ii) Cuff & Collar given for 2wks iii) Active joint movements started Lower limbs : i ) Plaster discarded ii) Elasto creep bandage applied for 3 wks iii) Active joint movements started iv) Wt bearing allowed under supervision

17. FUNCTIONAL CAST BRACING (FCB ): Common disabilities at the end of fracture treatment are—muscular wasting and joint stiffness –fracture disease—bone is osteoporotic . FCB is a method of conservative management of fractures which permits functioning of the joints and muscles of the limb , while immobilizing the fracture. BASIC PRINCIPLE OF FCB: SERMIENTO :- controlled motion physiologically induced is the single most important factor in osteogenesis .

18. Disadvantage of the plaster cast immobilization is the stiffness of joints and circulatory stagnation due to prolonged immobilization and disuse of the limb. This is avoided in FCB . Eg .. Fracture tibia -- Above knee pop cast for 3 wks – once fracture is sticky then apply PTB cast with ankle hinge (FCB) at second stage .

19. TRACTION : Used for reduction (continuous traction ) and for immobilization of some fractures of lower limbs. As per method of application Types – i )skin traction ii) skeletal traction or pin traction As per its action Types – i ) balanced traction – traction and counter traction ii) fixed traction SPLINTS : used for transportation Eg .. Thomas splint

20. CLOSED REDUCTION AND INTERNAL FIXATION Eg ..EC # NOF or colles # closed manipulative reduction done under “C” arm control , and fracture fixed or immobilized internally with screws, plates or k-wires. OPEN REDUCTION AND INTERNAL FIXATION INDICATIONS : Closed method of reduction failed . Avulsion fracture -- # patella Difficulty in holding the fragments by closed method eg . IC # NOF . Intra- articular fractures Multiple fractures Pathological fractures Complicated fractures Nonunion fractures

21. METHODS OF INTERNAL FIXATION : SREWS -- Cortical screws, Cancellous screws, Malleolar Screws. PLATE & SCREWS -- for # BB forearm. Small DCP , Narrow DCP, Broad DCP, LCP. WIRES -- K-Wires IM NAILS – V- Nail, K-Nail, Rush Nails, Sq.. Nails IL NAILS – Tibia , Femur, Humerus ADVANTAGES OF ORIF : i ) Rigid immobilization of # ii) Early mobilization of joint Iii) Quick restoration of function DISADVANTAGES : i ) Infection ii) Blood supply disturbed Iii) Fracture healing process is disturbed.

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