Principles in fractures management

Presented at AW Sjahranie Hospital under supervision of dr. David SpOT

1. Principles in Fractures management Isa Basuki

2. DEFINITION OF FRACTURE A fracture is a break in the structural continuity of bone. 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 Fractures result from : Injury repetitive stress abnormal weakening of the bone (a ‘ pathological’ fracture )

3. FRACTURES DUE TO INJURY

4. FATIGUE OR STRESS FRACTURES Bone , like other materials , reacts to repeated loading . On occasion , it becomes fatigued & a crack develops e.g military installations , ballet dancers & athletes. A similar problem occurs in individuals who are on medication that alters the normal balance of bone resorption and replacement E.G. patients with chronic inflammatory diseases who are on treatment with steroids or methotrexate

5. PATHOLOGICAL FRACTURES Fractures may occur even with normal stresses if the bone has been weakened by a change in its structure e.g . in osteoporosis, osteogenesis imperfecta or Paget’s disease or through a lytic lesion e.g . a bone cyst or a metastasis.

6. DIAGNOSIS Clinical features Radiology (x-Ray)

7. CLINICAL FEATURES History of Trauma Symptoms and signs: Pain and tenderness Swelling Deformity Crepitus Loss of function Nerve and vascular injury

8. RADIOGRAPHIC FINDINGS Plain x-ray  should show joint above and joint below in at least 2 views, special view on request CT SCAN MRI  It is not helpful in fract ure diagnosis other than delineating associated injuries to the CNS , S ubtrochanteric (ST) disruption or occasionally fatigue fract ure

9. FRACTURE CLASSIFICATION Anatomical Location Condition of overlying st Direction of fracture line Mechanism of injury Whether the fracture is linear or comminuted AO classification

10. AO CLASSIFICATION A: simple fracture B: wedge fracture C: complex fracture

11. AO CLASSIFICATION

12. AO CLASSIFICATION

13. AO CLASSIFICATION

14. OPEN AND CLOSE FRACTURE

15. MECHANISM OF INJURY CLASSIFICATION Direct Trauma Indirect Trauma

16. DIRECT TRAUMA Tapping fractures Crushing fractures Penetrating fractures: High velocity  > 2500 f/s Low velocity  < 2500 f/s

17. INDIRECT TRAUMA Traction or tension fractures Angulation fractures Rotational fractures Compression fractures

18. FRACTURE MANAGEMENT TREATMENT OF CLOSED FRACTURES TREATMENT OF OPEN FRACTURES

19. TREATMENT OF CLOSED FRACTURES Emergency carE (SPLINTING) Definitive Fracture Treatment Rehabilitation ( muscle activity and early weightbearing are encouraged)

20. EMERGENCY CARE (SPLINTING) Splint them where they lie Adequate splinting is desirable Type of splints: Improvised conventional

21. DEFINITIVE FRACTURE TREATMENT The goal of fracture treatment is to obtain union of the fracture in the most anatomical position compatible with maximal functional return of the extremity 2 types of Definitive fracture treatment: Conservative Surgical

22. CONSERVATIVE Reduction: if displaced  under general anasthesia, the sooner the better Steps of Reduction: Traction Align (which fragment) Reverse mechanism of injury Immobilization: POP (Plaster of Paris) cast, slab, traction (fixed or balanced) Rehabilitation

23. CLOSED REDUCTION Traction in the line of the bone Disimpaction Pressing fragment into reduced position

24. Closed undisplaced closed, reducible  Conservative treatment Below knee Above knee

25. PLASTER OF PARIS (POP)

26. SLAB OR SPLINT

27. TRACTION

28. SURGICAL Open Reduction Internal Fixation (ORIF) Percutaneous Pinning External Fixation

29. OPEN REDUCTION INDICATIONS Operative reduction of the fracture is indicated: when closed reduction fails when there is a large articular fragment that needs accurate positioning for traction (avulsion) fractures in which the fragments are held apart

30. INTERNAL FIXATION INDICATION Fractures that cannot be reduced except by operation Fractures that are inherently unstable and prone to re-displace after reduction Fractures that unite poorly and slowly Pathological fractures in which bone disease may prevent healing Multiple fractures where early fixation reduces the risk of general complications and late multisystem organ failure Fractures in patients who present nursing difficulties

31. TYPE OF INTERNAL FIXATION Interfragmentary screws Wires (transfixing, cerclage and tension-band ) Plates and screws Intramedullary nails

32. PLATES AND SCREWS Plates have five different functions : Neutralization to bridge a fracture and supplement the effect of interfragmentary lag screws Compression used in metaphyseal fractures where healing across the cancellous fracture gap may occur directly Buttressing ‘overhang’ of the expanded metaphyses of long bones Tension-band Allows compression to be applied to the biomechanically more advantageous side of the fracture Anti-glide to prevent shortening and recurrent displacement of the fragments

33. INTRA-MEDULLARY FIXATION Centro-medullary Unlocked Interlocking (static – dynamic – double locked) Condylocephalic cephallomedullary

34. An oblique fracture of the shaft of the femur, before and after reamed intramedullary fixation with a stout nail and interlocking screws. This treatment allows near immediate ambulation for the patient.

35. EXTERNAL FIXATION Indications: Fractures associated with severe soft-tissue damage (including open fractures) or those that are contaminated Fractures around joints that are potentially suitable for internal fixation but the soft tissues are too swollen to allow safe surgery Patients with severe multiple injuries Ununited fractures, which can be excised and compressed Infected fractures

36. REHABILITATION 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 guide the patient back to normal activity

37. TREATMENT OF OPEN FRACTURES INITIAL MANAGEMENT CLASSIFYING THE INJURY DEFINITIVE TREATMENT

38. INITIAL MANAGEMENT it is essential that the step-by-step approach in advanced trauma life support not be forgotten When the fracture is ready to be dealt with : The wound is carefully inspected any gross contamination is removed the wound is photographed The area then covered with a saline-soaked dressing The patient is given antibiotics Tetanus prophylaxis is administered The limb circulation and distal neurological status checked repeatedly

39. CLASSIFYING THE INJURY with Gustilo’s classification of open fractures ( Gustilo et al ., 1984 ): Type 1 – The wound is usually a small , clean puncture through which a bone spike has protruded. There is little soft-tissue damage with no crushing and the fracture is not comminuted (i.e. a low-energy fracture). Type II – The wound is more than 1 cm long , but there is no skin flap . There is not much soft-tissue damage and no more than moderate crushing or comminution of the fracture (also a low- to moderate-energy fracture ). Type III – There is a large laceration , extensive damage to skin and underlying soft tissue and, in the most severe examples, vascular compromise . The injury is caused by high-energy transfer to the bone and soft tissues. Contamination can be significant .

40. CLASSIFYING THE INJURY There are three grades of severity : type III A  the fractured bone can be adequately covered by soft tissue despite the laceration . type III B  there is extensive periosteal stripping and fracture cover is not possible without use of local or distant flaps . type III C  there is an arterial injury that needs to be repaired, regardless of the amount of other soft-tissue damage

41. PRINCIPLES OF TREATMENT All open fractures, no matter how trivial they may seem , must be assumed to be contaminated The four essentials are : Antibiotic prophylaxis . Urgent wound and fracture debridement . Stabilization of the fracture . Early definitive wound cover.

42. Wound extensions for access in open fractures of the tibia Wound incisions (extensions) for adequate access to an open tibial fracture are made along standard fasciotomy incisions : 1 cm behind the posteromedial border of the tibia and 2–3 cm lateral to the crest of the tibia as shown in this example of a two-incision fasciotomy . The dotted lines mark out the crest (C) and posteromedial corner ( PM) of the tibia (a) These incisions avoid injury to the perforating branches that supply areas of skin that can be used as flaps to cover the exposed fracture (b) This clinical example shows how local skin necrosis around an open fracture is excised and the wound extended proximally along a fasciotomy incision (c,d)

43. The external fixator may be exchanged for internal fixation at the time of definitive wound cover as long as: the delay to wound cover is less than 7 days wound contamination is not visible Internal fixation can control the fracture as well as the external fixator

44. AFTERCARE In the ward, the limb is elevated and its circulation carefully watched . Antibiotic cover is continued but only for a maximum of 72 hours in the more severe grades of injury Wound cultures are seldom helpful , if it were to ensue, is often caused by hospital-derived organisms

45. REFERENCES Solomon L, Warwick DJ, Nayagam S. Apley’s System of Orthopaedics and Fractures . CRC Press; 2010. F . Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G. Hunter, Raphael E. Pollock, et al. Schwartz’s Principles of Surgery. 9th ed . New York/US: McGraw-Hill Education - Europe; 2009.

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