Fracture treatment A/ Reduce the fracture: Closed reduction Open reduction Articular fractures: Need anatomical reduction

Fracture treatment A/ Reduce the fracture: Closed reduction Open reduction Articular fractures: Need anatomical reduction Diaphyseal fractures Need functional reduction Restore length, axis, and rotation

Fracture treatment B/ Hold reduction until healing: Methods of holding reduction Sustained traction Cast splint Functional bracing Internal fixation External fixation

Fracture Management Treatment of closed fractures Treatment of open fractures Different

Treatment of closed fractures Emergency care (splinting) Definitive fracture treatment Rehabilitation muscle activity and early weightbearing are encouraged

Emergency care (splinting) Splint them where they lie Adequate splinting is desirable Type of splints: Improvised conventional

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 Rehabilitation

Closed reduction 1. Traction in the line of the bone 2. Pressing fragment into reduced position 3. Disimpaction

Absolute: when closed reduction fails when there is an articular fragment that needs accurate positioning for traction (avulsion) fractures in which the fragments are held apart Relative: Multiple fractures Pathological fractures To encourage early mobilization and avoid joint stiffness. e.g. Diaphyseal fractures Indications of Open reduction

Type of internal fixation Screws Wires Plates and screws Intramedullary nails

Operative Vs non-operative CriteriaOperativeNon-operative Risk of joint stiffnessLowPresent RehabilitationRapidSlow Risk of mal-unionLowPresent Risk of non-unionPresent Speed of healingSlowRapid Risk of infectionPresentLow Cost??

External fixation Indications in acute trauma: 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

Rehabilitation Restore function of the injured parts and, patient as a whole The objectives are: to reduce edema preserve joint movement restore muscle power guide the patient back to normal activity

Treatment of open fractures The four essentials are: Antibiotic prophylaxis Urgent wound and fracture debridement Stabilization of the fracture ? External Fixation Early definitive wound cover To be discussed separately

Complications of Fractures Nonunion (failure to heal) 3% overall 50% of some particular fractures Related to treatment, local problems, systemic problems (e.g. Smoking)

Complications of Fractures Malunion: (Healing in poor position) Deformity Risk of arthritis

Complications of Fractures Fat embolism syndrome Marrow elements (fat) released into the vascular system and travel to the lungs Triglycerides (fat) metabolized to FFA by pneumatocytes and these FFS are toxic to tissue Especially brain, blood vessels, kidneys ARDS Risk of death

Fat Embolism Diagnosis ARDS Mental status changes Petechial hemorrhage Other Treatment Respiratory Support Early recognition

Complications of Fractures DVT/Pulmonary embolism Fracture leads to immobilization Stasis, hypercoagulability, intimal injury Thrombosis of LE veins Embolism to heart and then lungs Mechanical blockage Ventilation/perfusion mismatch

DVT Prevention Mobilization Patient Limb Mechanical Skeletal stabilization SCD, foot pumps Compression Chemical anticoagulation

Pitfalls in Fracture Management History of mechanism of injury not obtained Combination injury missed Soft tissue not considered Failure to consider occult fractures X-rays not proper; exposure, views.. Inadequate film accepted

Summary What is a Fracture – the soft tissue part Fracture types Relation between fracture and force How fractures heal Principles of imaging Principles of treatment Complications of fractures

What type of fracture? Comminuted

What type of fracture? Compressed

What type of fracture? Comminuted

What type of fracture? Comminuted

Reading X-rays Identify patient’s name, number Identify anatomic region/structure and views Comment on bone and soft tissue quality Comment on x-ray quality, two jointsm two views, ….

Reading X-rays Site of fracture: Diaphysis, metaphysis, epiphysis, intra-articular Description of fracture and fracture line Simple, transverse, oblique, spiral, wedge butterfly, comminuted, segmental, compressed, impacted, avulsed, …. (If stuck, follow the cortex !) Describe deformity (displacement of distal in relation to proximal) Angulation, rotation, displacement, shortening, distraction

Location Which bone? Thirds (long bones) Proximal, middle, distal third Anatomic orientation E.g. proximal, distal, medial, lateral, anterior, posterior Anatomic landmarks E.g. head, neck, body / shaft, base, condyle Segment (long bones) Epiphysis, physis, metaphysis, diaphysis Epiphysis Metaphysis Diaphysis (Shaft) Physis Articular Surface

Displacement vs. angulation Displacement: Describes position of distal fragment in relation to proximal Angulation: Describes position of apex of angulation Apex lateral (valgus) angulation Varus displacement