EXTREMITY FRACTURES

Daryl M. Apla-on, MD, FPOA, FPCS

FRACTURES
 Break in the continuity of the bone
 Closed
 Open
 Dislocation
 Subluxation
 Sprain
 Strain
Shoulder Dislocation
Sprain
General Guidelines for Emergency Care
Mechanism of Musculoskeletal
Injuries
SIGNS AND SYMPTOMS OF FRACTURES

▪ Pain
▪ Deformity
▪ Length
▪ Angulation
▪ Rotation
▪ Swelling / ecchymosis
▪ Loss of function
▪ Grating
▪ Exposed bone ends
POTENTIAL COMPLICATIONS OF
FRACTURES
▪ Bleeding
▪ Compartment Syndrome
▪ Pain
▪ Pallor
▪ Pulselessness
▪ Paresthesias
▪ Paralysis
 GENERAL PRINCIPLES OF ASSESSMENT
AND MANAGEMENT

 Primary survey – ABC

 Control of external hemorrhage

 A PATIENT WITH MULTIPLE FRACTURES REQUIRE

IMMEDIATE TRANSPORT, IMMOBILIZE THE WHOLE PATIENT
ON A LONG BACKBOARD
 GENERAL PRINCIPLES OF ASSESSMENT
AND MANAGEMENT

 Secondary Survey
 Determine the mechanism of injury
 Identify chief complaint
 Head-to-toe survey
 Assess the neurovascular status of the injured extremity
 GENERAL PRINCIPLES OF ASSESSMENT
AND MANAGEMENT

 Expose the entire extremity.

 Dress wounds before splinting the fractures.
 Check – distal pulses, motor function and sensation.
ALWAYS CHECK THE PULSE, STRENGTH,
AND SENSATION DISTAL TO A
MUSCULOSKELETAL INJURY

RADIAL PULSE DORSALIS PEDIS POSTERIOR TIBIAL

 GENERAL PRINCIPLES OF ASSESSMENT
AND MANAGEMENT

 Straighten severely angulated fractures

 If you encounter resistance, DO NOT USE FORCE.
 DO NOT try to straighten deformities involving joints.
 Splint them in the position which they are found.
 GENERAL PRINCIPLES OF ASSESSMENT
AND MANAGEMENT

 Purpose of splinting:
 Alleviates pain
 Prevent further injuries
 Prevent a closed fracture from becoming an open type fracture
 Prevent further damage to surrounding soft tissues
 Helps control bleeding
 Facilitate transport
 Acquire adequate radiographic evaluation
GENERAL PRINCIPLES OF ASSESSMENT
AND MANAGEMENT
 For open fractures
 DO NOT attempt to push exposed bones ends back beneath the skin.
 Immobilize the joint above and below the fracture.
 Re-check the neurovascular status. Free the hands and feet from the splint
to access periodic evaluation of the distal pulses.
 GENERAL PRINCIPLES OF ASSESSMENT
AND MANAGEMENT
 Pad rigid splints generously.
 Be sure to immobilize all the fractures before moving the patient.
 Elevate the injured extremity once it splinted.
 When in doubt, SPLINT.
Strategies of Splinting
- Elbow -
 Strategies of Splinting
- Applying a vacuum splint -
Splinting the forearm and fingers
Strategies of Splinting
 Strategies of Splinting
- Applying a traction splint -
 Strategies of Splinting
- Applying a traction splint -
Strategies of Splinting
- Long Bone -
Gustilo open fracture Classification
I Open fracture, clean wound, wound <1 cm in length
II Open fracture, wound > 1 cm but < 10 cm in length[4] without extensive
soft-tissue damage, flaps, avulsions
III Open fracture with extensive soft-tissue laceration (>10 cm[4]), damage, or
loss or an open segmental fracture. This type also includes open fractures
caused by farm injuries, fractures requiring vascular repair, or fractures that
have been open for 8 hr prior to treatment
III A Type III fracture with adequate periosteal coverage of the fracture bone
despite the extensive soft-tissue laceration or damage
III B Type III fracture with extensive soft-tissue loss and periosteal stripping and
bone damage. Usually associated with massive contamination. Will often need
further soft-tissue coverage procedure (i.e. free or rotational flap)
III C Type III fracture associated with an arterial injury requiring repair,
irrespective of degree of soft-tissue injury.
Type I
Type II
Type III A
Type III B
Type III C
Type III injuries
 Farm Injuries
 High velocity gunshot wounds
 Shot gun wounds
 Open Fractures more than 8 hours post injury
 Mass casualties
 Open segmental fractures
 Traumatic amputations
Principles in the Management of Open
Fractures
 Treat open fractures as emergency
 Give antitetanus prophylaxis
 Give appropriate antibiotics
 Do debridement of wound
 Stabilize the fracture
 Plan for wound coverage
 Plan for rehabilitation
 Fracture Type Clinical Infection rate (%) Antibiotic Choice Antibiotic Duration
I 1.4 Cefazolin Every 8 hours for 3 doses

II 3.6 Piperacillin Tazobactam or Continue for 24 hours after

Cefazolin and tobramycin wound closure

III A 22.7 Piperacillin Tazobactam or Three days

Cefazolin and tobramycin plus
penicillin for anaerobic bacteria if
needed

III B 10-50 Piperacillin Tazobactam or Continue for three days after

Cefazolin and tobramycin plus wound closure
penicillin for anaerobic bacteria if
needed

III C 10-50 Piperacillin Tazobactam or Continue for three days after

Cefazolin and tobramycin plus wound closure
penicillin for anaerobic bacteria if
needed

Indian J Orthop. 2008 Oct-Dec; 42(4): 377–386.

Rest Ice Compression Elevation
Thank you for listening