Principle of Fractuers treatment
Ass.Prof.Dr. Zaid Al- Shahwanii Consultant Orthopedic SurgeonTreatment
Prevention is the most effective way to avoid fractures. Wearing protective helmet, or using protective equipment, such as safety gear, while playing sports may greatly reduce the risk of a fracture a Broken bones need to be treated as soon as possible by a specializt2)Temporary measures include applying ice packs to injured areas, and the use of aspirin or non steroidal anti-inflammatories (NSAIDS) to reduce pain and swelling. Initial first aid for a fracture may include splinting, control of blood loss, and monitoring of vital signs, such as breathing and circulation.
3) Immobilization of the fracture site can be done internally or externally Immobilization by external fixation uses splints, casts, or braces; Open reduction is surgery that is usually performed by an orthopedist Internal fixation devices, such as metal screws, plates, and pins, hold the bones in place as they heal. Open reduction is most often used for open, severe, or comminuted fractures which can be treated by external fixation . Fractures with little or no displacement of the bones do not usually require such surgery.
The primary treatment of compound fractuers includes:- A) Early operative debridement procedure B) Bone stabilization
A ) Early Operative Debridement include
Exploration of the wound to define the zone of injury
Removal of devitalized tissue as non-viable skin and muscle, and mechanical lavag for any foreign article’s as clothes,missels & shells, mud &dirts
Fasciotomy should be performed & evacuation of haematoma
Removal of Small to medium-sized avascular bone fragments
The initial primary traumatic wound should be left open while operative extension of the initial wound may be primarily , sutured
Extensive soft tissue damage should be reinspected and additional debridement performed within24-48 hours
B ) Bone stablization
Casting ..
Traction either (skin or skeletal ) .
External fixation with or without minimal internal fixation..
Internal fixation if the condition allow.
are the main lines for treating a war injured patient with compound fracture
Traction skin or skeletal traction
Advantage
Is a simple and safe method for fracture holding, especially for the lower limb
It can be used for initial and definitive stabilization and allows easy wound access and joint mobilization.
It gives a rapid callus formation.
Disadvantages
long bed rest,leading to resp.&urinary infection plus bed sore
Difficult access to the buttock and posterior aspect of thigh and leg,
Male-union ((difficulties in getting a perfect alignment of the fracture))
Traction can be applied in different forms: gallows traction for femur fractures in babies up to 3 years or 15 kg of body weight,
skin traction for older children & adult patient
SKELETAL or pin-Traction for pelvis ,femur & tibial fracture
External Fixators Give a very good results when correctly applied for the correct indications in most of the cases ,,but it’s not the only way to treat all fractures in war surgery,
External fixation is the primary form of initial long-bone fracture stabilization for soldiers treated in battlefield hospitals or civilian victims of explosions& accident’s
Once the patient is in a stable environment, the receiving surgeon can either continue with external fixation specially if an extended periods of time are needed to deride wounds adequately,,,, or select a different treatment method for definitive treatment as intra-medullary nailing (IM-nailing)
Indication For External Fixator
1)Open compound fracture
2)Multiple fractures
3)Fracture +vascular injuries
4) Fracture pelvis
5)Periarticular fracture
6)Bone sliding & bone lengthening
7)Pathalogical # as bone Tu. ,,osteomylitis.
Advantage of external fixator
1) easily applied considering the corridors
2) no soft tissue stripping
3) easily removed .
4)Ease the patient transfer & movement
5)Free & Mobil joint above & the joint below
6)Help other specialties to interfer. (plastic & neruo-surgery.) ,
Disadvantage of external fixator
1)Pin tract infection
2) Mal –union
3) Non-union
4) injury to neuro_vascular bundle
5)fracture through pin tract.
6)broken pin
7)losening of the clamps
Gustilo classification of Open Fr.
I - Low energy- wound less than 1 cm, minimal contamination ,comminution, and soft-tissue damage (infection rat 0-2 %)II - Wound greater than 1 cm (2-5 ) with moderate soft tissue damage, minimal periosteal stripping wound bed is moderatedly contaminated (infected rate 2-5 %)
III- High energy –wound greater ((5- 10 0r more )) with extensive soft tissue damage
A - Severe soft-tissue damage and substantial contamination; coverage adequate , segmental fracture with displacement or fracture with diaphyseal segmental loss;no neuro-vascular injury (infection rate10 -15%)
B - same as above + soft tissue is inadequate for cover and requires regional or free flap usually associated with major nerve injury. ( infection rat 15- 25%)
C - same as the above + arterial injury ( infection rat 25-50 %)
Closed fracture
To align the fragments as it is more important than perfect opposition except in intra-articular fractures where perfect reduction is a must.
Methods
1.Closed method: reducing the fracture without opening the site of fracture.
It is done for minimally displaced fracture and most fractures in children.
It must be done under anaesthesia. This is done by:
• Pulling on the distal fragment in the longitudinal line of the bone so
that the distal fragment is away from the proximal one
• Reverse the direction of the force that caused the fracture
• Align any other plane displacements as nearly as possible to
their correct position.
2. Open reduction: if you are not successful in the previous one.
Indications:
• Failure to reduce the fracture by the closed method
• Intra-articular fracture that requires perfect reduction
• Avulsion fracture (the fragments are pulled apart by one of the muscles attached to them) e.g. in patellar fracture the fragments can be pulled by the action of quadriceps muscle.
The choice of the method depends upon the site and pattern of the fracture.
B . Immobilise
To hold the reduction; aiming at:
1. Relief pain 2. Prevent displacement or angulation of the fragments 3. Ensure good position for union 4. Promote soft tissue healing 5. Allow free movements of the unaffected part
Methods:
1. Continuous traction; in some fractures - notably those of the shaft of the femur and certain fractures of the shaft of the tibia - it may be difficult or impossible to hold the fragments in proper position by a plaster or external splint alone. This is particularly so when the plane of the fracture is oblique or spiral, because the elastic pull of the muscles tends to draw the distal fragment proximally so that it overlaps the proximal fragment. In such a case the pull of the muscles must be balanced by continuous traction upon the distal fragment, either by weight or by some other mechanical device.
2. Cast splintage: apply POP (plaster of Paris). Plaster of Paris is hemihydrated calcium sulphate.
3. Functional bracing: it is made up of plastic material that consists of two segments joint by a hinge to avoid joint stiffness.
Gypsona: consists of a leno-weave gauze fabric that is coated with a blend of the alpha and beta forms of calcium sulphate hemihydrate (plaster of Paris), together with binders and accelerators. The use of a leno-weave gauze is claimed to provide stability to the bandage, and reduce distortion and creasing during application.
4. Internal fixation: it is usually desirable in adults. It achieves good reduction and immobility and the complications will be less.
Indications
• Fracture that can't be treated by other mains. • Unstable fracture that is known to unite poorly • Pathological fracture • Poly-traumatised patient to decrease the risk of RDS • Fracture in a patient with nursery difficulties
Methods of internal fixation:
• Plate held by scews • Bone graft held by screws • Intramedullary nail • Nail-plate (combined nail and plate) • Transfixation screws • Circumferential wires or bands • Suture through attached soft tissues
DIAGNOSIS OF HEALING
ClinicalThe limb is less swollen, the bruising disappears, no abnormal movement and the patient can move the limb.
Radiological X ray shows the callus and obliteration of fracture line