APPROACH TO FRACTURE

1. Clinical Assessment
 Primary survey: Airway, Breathing, Circulation, Deformity & Disability, Exposure and
Environmental situation
 Secure airway and stop bleeding
 Rule out brain injuries/ increased ICP
 Rule out other fractures/ injuries
 Rule out open fractures
 Simple history including -SAMPLE history
o Symptoms
o Allergies
o Medications & drugs
o Past medical and surgical history
o Last meal
o Events leading to injury/ accident
 Physical examination
o Look – deformity, soft tissue integrity
o Feel – tenderness, neurovascular status
o AVOID move to prevent exacerbation
2. Analgesia
3. Imaging: Rule of 2s
 2 sides – bilateral
 2 views – AP + lateral view
 2 joints – one joint above & below
 2 times – before and after reduction

4. Definite management: Reduce, Hold, Exercise

(A) REDUCE
 Always recheck neurovascular status and obtain post-reduction X-ray after reduction

Closed Reduction
 IV sedation and muscle relaxation
 Types of block – hematoma block, sural block
 Reverse the mechanism that produced the fracture & realignment of bones
 Skeletal/ skin traction might be needed for fracture that is difficult to reduce due to powerful
muscle pull, eg. femur, tibia, supracondylar fractures [Buck’s traction for lower limb, lateral
traction for humeral fracture]

Open Reduction
 Failed closed reduction
 Not able to cast or apply traction due to site, eg. hip fracture
 Pathologic fractures
 Potential improvement with ORIF
 Indications: NO CAST
o Non-union
o Open Fracture
o Neurovascular Compromise
o Displaced intra-Articular Fracture
o Salter-Harris 3,4,5 [fracture passes through epiphysis and metaphysis of bone]
o PolyTrauma
(B) HOLD
 External stabilisation: splint, cast, traction, external fixator
1) Traction under gravity – only for upper limb
2) Skin Traction
- Buck’s skin traction [max 5kg]
3) Skeletal Traction
 Internal stabilisation: percutaneous pinning, extramedullary fixation (screws, plates, wires),
intramedullary rods

(C) EXERCISE – to regain function and avoid joint stiffness

Adhesive plaster – Holland strap

+ for young children and thin elderly
SKULL TONG – FOR cervical spine traction
https://www.slideshare.net/kywong5005/ortho-splinting-traction-pop
slide
PLASTER OF PARIS (POP)
Cast – whole circumference of limb
Slab – half circumference of limb and secured with cotton bandages
 8 inches for thigh, 6 inches for leg, 4 inches for arm
 use hot/ warm water will dry the plaster faster (but at the same time need to apply faster
before it dries out)
 apply 4-6 layers (up to 10-12 layers for lower limb)
 create oval ‘window’ if need to inspect wound; must put back the cut piece back to the area
to avoid ‘window edema’, where tissue herniates through the hole as it swells
 for lower limb: apply cast with leg flexed at 30o, as it is the physiological position when human
walk
+ Burns

COMPARTMENT SYNDROME: 6Ps

 Pain – out of proportion (not relieved by painkillers) [earliest sign]
 Paresthesia
 Paresis (partial paralysis)
 Pulselessness
 Pallor
 Poikilothermia [inability to regulate core temperature]