Treatment for closed fracture

First consideration-general treatment-treat the

patient, not the fracture 3 principles:

hold-hold until unite reduce improve position of fragmnets Exercise- promotes fracture healing

Reduction
aim for adequate apposition and normal alignment

of the bone fragments The greater the contact surface area between fragments the more likely healing is to occur
Two methods

Closed reduction

Open reduction

Closed reduction
Done under appropriate anaesthesia and muscle

relaxation three-fold manoeuvre: 1. the distal part of the limb is pulled in the line of the bone 2. as the fragments disengage, they are repositioned 3. alignment is adjusted in each plane.

Difficulty in reduction due to powerful muscle pullskin traction or skeletal traction

Open reduction
Operative reduction of the fracture under direct

vision is indicated: 1. when closed reduction fails 2. when there is a large articular fragment that needs accurate positioning 3. for traction (avulsion) fractures in which the fragments are held apart

Immobilization

Methods of holding reduction

Sustained traction Cast splintage Functional bracing Internal fixation External fixation

Casts and Splints

Appropriate for many fractures

especially hand and foot fractures Adults typically will get plaster splints initially transitioned to fiberglass casts as swelling decreases Kids typically will get fiberglass casts

Complications of cast splintage

Tight cast

Pressure sores
Skin abrasion or laceration Loose cast

Traction
Useful in patients who are too sick for surgery

Useful to maintain alignment until definitive fixation

Traction by gravity

Skin traction: fixed

Skin traction: balanced

Skeletal traction

Operative
ORIF (open reduction internal fixatation)
Pin & wire fixation. Screw fixation. Plate & screws fixation. Intra-medullary fixation.

External fixation

screws

Plate & screws

Flexible Intramedullar nails

Sinple k-wires

Indications of ORIF
Absolute Indications for ORIF of fractures Unable to obtain an adequate reduction Displaced intra-articular fractures Certain types of displaced epiphyseal fractures Major avulsion fractures where there is loss of function of a joint or muscle group Non-unions Re- implantations of limbs or extremities

Relative Indications for ORIF of fractures

Delayed unions Multiple fractures to assist in care and general

management Unable to maintain a reduction Pathological fractures To assist in nursing care To reduce morbidity due to prolonged immobilisation For fractures in which closed methods are known to be ineffective

EXTERNAL FIXATION
Indications Fractures associated with severe soft-tissue damage 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 Ununited fractures Infected fractures

External fixation cont,