CLOSED AND OPEN FRACTURES MODERN METHOD OF TREATMENT OF FRACTURES

PROFESSOR Fishchenko Vladimir Alexandrovich

BASHINSKIY GENNADIY PETROVICH

Fracture Fracture it is damaged bone tissue due to injury. Fracture it is damaged bone tissue due to injury. Can be open and closed fractures. Can be open and closed fractures. In the case of a closed fracture of the skin remains undamaged. In the case of a closed fracture of the skin remains undamaged.

A fracture is open when a break in the skin over it brings it into communication with organisms of the outside world. A fracture is open when a break in the skin over it brings it into communication with organisms of the outside world. Can be the primary- and secondary-open fractures. Primary open fractures occur at the time of injury. Secondary open fractures occur during hospital transport, due to poor immobilization. All gunshot fractures are open fractures in primary. Can be the primary- and secondary-open fractures. Primary open fractures occur at the time of injury. Secondary open fractures occur during hospital transport, due to poor immobilization. All gunshot fractures are open fractures in primary.

15 GOLDEN RULES FOR FRACTURES 1. If a patient is severely injured,save his life first; treat any airway obstruction, haemorrhage, or shock before you treat this fractures

2 Splint him where he lies, when you first see him; this will minimize soft tissue damage and avoid converting a closed fracture into an open one. 2 Splint him where he lies, when you first see him; this will minimize soft tissue damage and avoid converting a closed fracture into an open one. 3 Look for signs of nerve and vessel injuri and record your findings 3 Look for signs of nerve and vessel injuri and record your findings

4 Handle his injured part as little as you can 4 Handle his injured part as little as you can 5 If he has an obvious fracture, make sure that this is his only injury – it may be the least of his injuries. Don’t let him die from a tension pneumothorax while you are treating а fracture of his forearm! 5 If he has an obvious fracture, make sure that this is his only injury – it may be the least of his injuries. Don’t let him die from a tension pneumothorax while you are treating а fracture of his forearm!

6 Don’t be deceived by the absence of deformity and disability; sometimes he can continue to use his fracture limb. 6 Don’t be deceived by the absence of deformity and disability; sometimes he can continue to use his fracture limb. 7 Take X-rays in 2 planes and examine them yourself. 7 Take X-rays in 2 planes and examine them yourself.

8 Reduce the fracture as soon as you can, don’t wait for swelling to go down. 8 Reduce the fracture as soon as you can, don’t wait for swelling to go down. 9 If he has continuous severe pain suspect circulatory impairment and treat it immediately. 9 If he has continuous severe pain suspect circulatory impairment and treat it immediately.

10 When you split a cast, devide the plaster and the padding right down to his skin. 10 When you split a cast, devide the plaster and the padding right down to his skin. 11 If you put him into traction, be sure to cheсk this freguently. 11 If you put him into traction, be sure to cheсk this freguently.

12 All joint that are not immobilized by the fracture must be kept moving. 12 All joint that are not immobilized by the fracture must be kept moving. 13 Remember that open fracture are contaminated wounds, so toilet them and use delayed primary closure. 13 Remember that open fracture are contaminated wounds, so toilet them and use delayed primary closure.

14 Aim to restore function. If a patient’s arm is injured, try to restore the proper use of his hand; shortening and some misalignment are often acceptable. If his leg is injured try to restore painless stable weight bearing; prevent misalignment; maintaining length is desirable, but а little shortening is acceptable 14 Aim to restore function. If a patient’s arm is injured, try to restore the proper use of his hand; shortening and some misalignment are often acceptable. If his leg is injured try to restore painless stable weight bearing; prevent misalignment; maintaining length is desirable, but а little shortening is acceptable

15 Finally, remember to treat him as a whole person; don’t only treat his injured limb. 15 Finally, remember to treat him as a whole person; don’t only treat his injured limb.

Fracture of the neck of the femur (or hip fracture ) - a serious injury that if performed incorrectly or delayed treatment can lead to serious consequences : disability, and some cases of death of the victim, especially in the elderly. Treatment of these fractures is very difficult. Unfavorable conditions for the seam due to local anatomical features and the difficulty of immobilization ( ensure immobility ). Bone fracture healing occurs within 6-8 months. At the same time, prolonged bed rest in the elderly leads to congestive pneumonia, bedsores, venous thromboembolism, which is the main cause of high mortality. Therefore, the methods of treatment associated with prolonged immobilization of the patient, the elderly should not be used. Femoral neck heals very poorly because of the peculiarities of the structure and blood supply. Fusion of such fractures without surgery is possible only in children. In patients older than 30 years the probability of self- fusion of hip fracture is negligible. That is why, in developed countries, the main method of treatment of hip fractures in adults is surgery. The operation called fixation of femoral neck is broken fixing bone parts in the correct position. Most often, for fixing bone fragments using special screws, made of high alloy steel. The transaction resulted in favorable conditions for the fusion of hip fracture, which occurs in about 4 months. After fixation of the femoral neck patient begins to walk on crutches already on the next day after surgery. However, the total load on the leg ( ie walking without crutches ) allowed not earlier than 4 months after surgery. Like any other surgery, osteosynthesis of the femoral neck is not devoid of drawbacks. The most important of these is nonunion. Even if the operation is successful, you can not completely eliminate the risk that a hip fracture can not grow together. Moreover, the older the patient, and the more time that has passed since the injury, the greater the risk of nonunion and the formation of the folse joint of the femoral neck. Fracture of the neck of the femur (or hip fracture ) - a serious injury that if performed incorrectly or delayed treatment can lead to serious consequences : disability, and some cases of death of the victim, especially in the elderly. Treatment of these fractures is very difficult. Unfavorable conditions for the seam due to local anatomical features and the difficulty of immobilization ( ensure immobility ). Bone fracture healing occurs within 6-8 months. At the same time, prolonged bed rest in the elderly leads to congestive pneumonia, bedsores, venous thromboembolism, which is the main cause of high mortality. Therefore, the methods of treatment associated with prolonged immobilization of the patient, the elderly should not be used. Femoral neck heals very poorly because of the peculiarities of the structure and blood supply. Fusion of such fractures without surgery is possible only in children. In patients older than 30 years the probability of self- fusion of hip fracture is negligible. That is why, in developed countries, the main method of treatment of hip fractures in adults is surgery. The operation called fixation of femoral neck is broken fixing bone parts in the correct position. Most often, for fixing bone fragments using special screws, made of high alloy steel. The transaction resulted in favorable conditions for the fusion of hip fracture, which occurs in about 4 months. After fixation of the femoral neck patient begins to walk on crutches already on the next day after surgery. However, the total load on the leg ( ie walking without crutches ) allowed not earlier than 4 months after surgery. Like any other surgery, osteosynthesis of the femoral neck is not devoid of drawbacks. The most important of these is nonunion. Even if the operation is successful, you can not completely eliminate the risk that a hip fracture can not grow together. Moreover, the older the patient, and the more time that has passed since the injury, the greater the risk of nonunion and the formation of the folse joint of the femoral neck.

Тreatment of fractures Тreatment of fractures are divided into conservative and operative. Тreatment of fractures are divided into conservative and operative. To Conservative methods include skeletal traction and plaster. To Conservative methods include skeletal traction and plaster.

Advantages of plaster immobilization: A simple method A simple method Cheap method Cheap method Plaster of Paris is hygroscopic Plaster of Paris is hygroscopic

Dezdvantages of plaster immobilization 1. May be a secondary displacement of the bone fragments after decrease of edema 1. May be a secondary displacement of the bone fragments after decrease of edema 2. After removal of plaster typically occurs joint contracture and muscle atrophy 2. After removal of plaster typically occurs joint contracture and muscle atrophy

Types of the plaster bandage Plaster bandage without padding Plaster bandage without padding Solid plaster bandage Solid plaster bandage Plaster bar Plaster bar Bridged plaster bandage Bridged plaster bandage Fenestrated plaster bandage Fenestrated plaster bandage Open plaster bandage, plaster splint Open plaster bandage, plaster splint Plaster bandage for padding Plaster bandage for padding Removable plaster bandage Removable plaster bandage

Hip plaster bandage Hip plaster bandage Thoracobrachial plaster bandage Thoracobrachial plaster bandage Circular/solid plaster bandage Circular/solid plaster bandage Hinged plaster bandage Hinged plaster bandage Plaster cast Plaster cast Lorenz plaster bandage Lorenz plaster bandage Whitman’s plaster bandage Whitman’s plaster bandage Plaster bad Plaster bad Plaster jacket Plaster jacket Plaster boot Plaster boot

REMEMBER 1. Apply a plaster bandage (glue extension) 1. Apply a plaster bandage (glue extension) Cut out a window in the bandage if patient has wound Cut out a window in the bandage if patient has wound 2. Put the extremity in a median physiological position 2. Put the extremity in a median physiological position 3. Attach to the (plaster) bandage the scheme of bony damage (the date of trauma, the date when the plaster was applied, the date when the plaster is to be removed, doctor’s name (your name) 3. Attach to the (plaster) bandage the scheme of bony damage (the date of trauma, the date when the plaster was applied, the date when the plaster is to be removed, doctor’s name (your name) 4. The bandage must not be too tight (loose) 4. The bandage must not be too tight (loose) 5. If the plaster bandage is too tight and painful Cut the cast along its length immediately 5. If the plaster bandage is too tight and painful Cut the cast along its length immediately

7. Turn back the edges to both sides; 7. Turn back the edges to both sides; 8. Faster the bandage by a circular plaster roller; 8. Faster the bandage by a circular plaster roller; 9. Remove the bandage. Apply a new one. 9. Remove the bandage. Apply a new one.

Skeletal traction Boeller’s splint Boeller’s splint Balkan frame Balkan frame Pulley in system of traction Pulley in system of traction Weight for traction Weight for traction Drill for passing a wire/pin Drill for passing a wire/pin Wrench to press and tighten a pin Wrench to press and tighten a pin Stirrup for skeletal traction Stirrup for skeletal traction Wire/pin for skeletal traction Wire/pin for skeletal traction

Skeletal traction 1. The patient is under traction 1. The patient is under traction 2. Apply calcaneus skeletar traction 2. Apply calcaneus skeletar traction 3. Pass the pin through the tuberosity of the tibia (greater trochanter, calcaneus bone, elbow process) 3. Pass the pin through the tuberosity of the tibia (greater trochanter, calcaneus bone, elbow process) 4. Pull the pin straight 4. Pull the pin straight 5. It,s necessary to establish countertraction 5. It,s necessary to establish countertraction

6. Add (reduse) weit 6. Add (reduse) weit 7. Establish additional lateral (front) countertraction 7. Establish additional lateral (front) countertraction 8. Raise the foot (heat) end of the bad 8. Raise the foot (heat) end of the bad 9. Place a foot-rest under the sound leg 9. Place a foot-rest under the sound leg

10. Have a control X-ray film made on the patient’s bed in two view’s in the ward 10. Have a control X-ray film made on the patient’s bed in two view’s in the ward 11. Is reposition of fragments satisfactory (right)? 11. Is reposition of fragments satisfactory (right)? 12. Is callus good (Has it developed)? 12. Is callus good (Has it developed)? 13. The pin should be removed observing all the rules of asepsis 13. The pin should be removed observing all the rules of asepsis

Intramedullary osteosynthesis 1. Operative reduction of fragments must be done 1. Operative reduction of fragments must be done 2. A metal nail must be done introduсed into the bone-marrow cavity of both fragments 2. A metal nail must be done introduсed into the bone-marrow cavity of both fragments 3. The diameter of the nail must be correspond to the bone-marrow cavity diameter 3. The diameter of the nail must be correspond to the bone-marrow cavity diameter 4. Choose a metal nail which corresponds in its length to that of the extremity (to the diameter of the bone-marrow cavity) 4. Choose a metal nail which corresponds in its length to that of the extremity (to the diameter of the bone-marrow cavity)

Extramedullary osteosynthesis It is a stable and functional osteosynthesis In this type of osteosynthesis using metal plates and screws. It is a stable and functional osteosynthesis In this type of osteosynthesis using metal plates and screws. The plates can be direct (fixation of fractures of the diaphysis) The plate can be angled (fixation of fractures of the femoral neck, femoral condyles, tibia) The plates can be direct (fixation of fractures of the diaphysis) The plate can be angled (fixation of fractures of the femoral neck, femoral condyles, tibia)

Extrafocal osteosynthesis Compression-distraction devices by type Ilizarov Used for the treatment of open, gunshot fractures and congenital diseases of the musculoskeletal system Compression-distraction devices by type Ilizarov Used for the treatment of open, gunshot fractures and congenital diseases of the musculoskeletal system