Closed reduction or manipulation
under anaesthesia for
Minimally displaced fractures.
Fractures in children.
Fractures that are stable after reduction.
Open reduction for
Failure of closed reduction.
Displaced intra articular fractures.
Unstable fractures.
Traction fractures.
Immobilise (Hold reduction)
Continuous traction is
applied to the limb distal to the fracture to exert continuous pull in the long
axis of the bone.
by gravity - a hanging cast for displaced
fractures of the humeral shaft.
by skin traction - two adhesive strips are
stuck on to either side of the leg and weights are attached to these strips
by a rope (for femoral shaft fractures in children).
by skeletal traction - through a pin placed
in the tibia for femoral shaft fractures in adults. This can be fixed or balanced.
Cast splintage
Can be plaster of Paris or synthetic casts.
A back slab is usually used initially followed
by a complete plaster when the swelling subsides.
Adequate padding must be used over bony
prominences.
The joint above and below the fractured
bone must be immobilised.
The limb must be elevated and circulation
distally should be checked.
Internal fixation
Indications
failure of closed reduction
unstable fractures
pathological fractures
fractures that unite poorly ( femoral neck)
multiple fractures
Method
Screws and plates
Steel wires
Intra medullary nails.
External Fixation
Transfixing screws are passed through the bone
and are attached to an external frame.
Types : Tubular ( A
O ), Ring (ILIZAROV)
Indications
Fractures associated with severe soft tissue
injury.
Severe multiple injuries (associated with
chest injury).
Pelvic fractures.
Infected fractures.
Exercise (Rehabilitation)
Prevent oedema - elevate limb.
Upper limbs - sling.
Lower limbs - elevate on pillows/chair.
Active exercise.
Helps circulation.
Decreases oedema.
Helps to avoid joint stiffness.
Gentle assisted movements are also helpful
( CPM ).
Gradual return to functional activity.
OPEN FRACTURES
Grade I (Gustilo & Anderson)
Small, clean wound less than 2 cm long.
No crushing or comminution.
Grade II
Wound 2cm to 5cm long. Slight contamination
Moderate crushing and comminution.
Grade III
Wound greater than 5cm.
Marked damage to soft tissues and considerable
contamination and comminution of fracture and periosteal stripping.
As in above but bone cannot be adequately
covered by soft tissue.
Associated nerve and vascular injury.
Early Management (Emergency Room
)
Dressing over the wound.
IV antibiotics
Tetanus prophylaxis
Temporary splinting (POP Slab )
Debridement
Irrigation with at least 3 litres of saline
(6-10 litres recommended)
No tourniquet.
Skin
Excise 2mm thickness at wound edges
- also any skin that is necrotic.
DO NOT SUTURE THE WOUND.
Muscle
4 'C's -
Colour
Consistency
Contractility
Capacity to bleed
Nerves
Leave cut nerve undisturbed.
Tendons
Leave cut ends alone - only suture if totally
clean.
Bone
Only remove small and totally detached fragments.
Clean and retain large fragments and those with some soft-tissue attachment.
Stabilising the fracture
Safest method is external fixation. Intra -
medullary nailing can be used for the tibia and femur. (If the wound is not
very contaminated and a thorough debridement has been done)
