management of closed fracture

orthopedic

1. Principle of closed fracture management By: Ekhlass Ramadan Norshan Jamal

2. A fracture is a break in the structural continuity of bone. It may be no more than a crack, a crumpling or a splintering of the cortex; more often the break is complete and the bone fragments are displaced.

3. If the overlying skin remains intact it is a closed (or simple) Fracture if the skin or one of the body cavities is breached it is an open (or compound) fracture, liable to contamination and infection

4. Diagnosis of fracture 1.History taking 2.Physical examination (general and local signs) 3.Investigations Remember the role of two ) ) a.Xray b.MRI c.CT scan d.Radioisotope scanning

5. Treatment of a fracture can be considered in three phases Phase I - Emergency care Phase II - Definitive care Phase III - Rehabilitation

6. Management of closed fracture General treatment is the first consideration: treat the patient, not only the fracture general treatment and resuscitation must always take precedence

7. Emergency care Emergency care of a fracture begins at the site of the accident . ABCDE 1.Rest to the part, by splinting. 2.Ice therapy, 3.Compression 4.Elevation In the emergency department It is most important to provide, if required, basic life support (BLS). If in shock, the patient is stabilized before any definitive orthopedic treatment is carried out

8. in addition to splintage , the patient should be made comfortable by giving him intramuscular analgesics. It is only after the emergency care has been given, and it is ensured that the patient is stable. He should be sent for suitable radiological and other investigation under supervision

9. Definitive care Reduce Fracture reduction and fixation to restore anatomical relationships Preservation of blood supply to soft tissue and bone by careful handling and gentle reduction techniques Hold important to maintain the bone in reduced position Exercise Early and safe mobilization of the part and patient .

10. R eduction swelling of the soft parts during the first 12 hours makes reduction increasingly difficult .

11. However, there are some situations in which reduction is unnecessary: 1 . when there is little or no displacement; 2 . when displacement does not matter initially (e.g. in fractures of the clavicle) 3 . when reduction is unlikely to succeed (e.g. with compression fractures of the vertebrae)

12. There are two methods of reduction 1.Closed reduction 2.Open reduction

13. Closed reduction In general, closed reduction is used for all minimally displaced fractures, for most fractures in children for fractures that are not unstable after reduction and can be held in some form of splint or cast . Unstable fractures can also be reduced using closed methods prior to stabilization with internal or external fixation.

14. HOLD The available methods of holding reduction are: • Continuous traction • Cast splintage • Functional bracing • Internal fixation • External fixation

15. Continuous traction 1.Traction by gravity 2 .Skin traction 3 .Skeletal traction Fixed traction Balanced traction

16. Complication of traction 1.Circulatory embarrassment In children especially, should never be used for children over 12 kg in weight. 2.Nerve injury In older people, leg traction may predispose to peroneal nerve injury and cause a drop- foot 3.Pin site infection Pin sites must be kept clean and should be checked daily

17. Cast splintage Plaster of Paris is still widely used as a splint, especially for distal limb fractures and for most children’s fractures.

18. Complications of cast 1.Tight cast 2.pressure sore 3.skin abrasion and laceration 4.loose cast

19. Functional bracing Segments of a cast are applied only over the shafts of the bones, leaving the joints free; The splints are ‘functional’ in that joint movements are much less restricted than with conventional casts. Functional bracing is used most widely for fractures of the femur or tibia, but since the brace is not very rigid, it is usually applied only when the fracture is beginning to unite, i.e. after 3–6 weeks of traction or conventional plaster.

20. Internal fixation Bone fragments may be fixed with screws, a metal plate held by screws, a long intramedullary rod or nail (with or without locking screws), circumferential bands or a combination of these methods. Properly applied, internal fixation holds a fracture

21. Indications 1 . Fractures that cannot be reduced except by operation. 2. Fractures that are inherently unstable and prone to re-displace after reduction (e.g. mid-shaft fractures of the forearm and some displaced ankle fractures). 3 . Fractures that unite poorly and slowly, principally fractures of the femoral neck.

22. 4. Pathological fractures 5. Multiple fractures where early fixation (by either internal or external fixation) reduces the risk of general complications and late multisystem organ failure. 6. Fractures in patients who present nursing difficulties (paraplegics, those with multiple injuries and the very elderly)

23. Types of internal fixation Intrafragmentary screw Wires (transfixing, cerclage and tension-band

24. Types of internal fixation Plates and screws Intramedullary nails

25. Complications of internal fixation 1.infection 2.non union 3.implant failure 4.refracture

26. External fixation A fracture may be held by transfixing screws or tensioned wires that pass through the bone above and below the fracture and are attached to an external frame. This is especially applicable to the tibia and pelvis, but the method is also used for fractures of the femur, humerus , lower radius and even bones of the hand

27. Indications 1. Fractures associated with severe soft-tissue damage (including open fractures) or those that are contaminated 2. Fractures around joints that are potentially suitable for internal fixation but the soft tissues are too swollen to allow safe surgery 3. Patients with severe multiple injuries, especially if there are bilateral femoral fractures, pelvic fractures with severe bleeding. 4. Ununited fractures, which can be excised and compressed 5. Infected fractures

28. Complications 1.Damage to soft-tissue structures 2.Overdistraction If there is no contact between the fragments, union is unlikely. 3.Pin-track infection This is less likely with good operative technique. Nevertheless, meticulous pin-site care is essential

29. Exercise More correctly, restore function – not only to the injured parts but also to the patient as a whole. The objectives are to reduce oedema , preserve joint movement, restore muscle power and guide the patient back to normal activity By : Prevention of oedema Elevation active exercise assisted movement functional activity

30. References Apley’s System of Orthopedics and Fracture Essential orthopedics