A high velocity injury should always be treated according to
the Advanced Trauma Life Support (ATLS) guidelines with attention
to Airway, Breathing and Circulation on presentation. The patient
should be optimally resuscitated before any fracture treatment is
considered. The basic principles of fracture treatment are
appropriate reduction, immobilization and early
rehabilitation.
Slide 3
Conservative treatment Most undisplaced or minimally displaced
fractures can be satisfactorily treated non- operatively either
with plaster immobilization (e.g. ankle fractures), slings (elbow
and shoulder fractures), strapping (e.g. phalangeal fractures) and
traction (e.g. paediatric femoral shaft fractures).
Slide 4
Closed reduction is usually achieved with manipulation under
anaesthetic or intravenous sedation. The injured limb can be
immobilized in a plaster, if the fracture displacement has
satisfactorily been reduced. Most displaced distal radius fractures
(e.g. Colles fractures) are treated in this way.
Slide 5
Signicantly displaced fractures, however, may require reduction
before immobilization.
Slide 6
Traction The aim is to apply an axial pull at the fracture site
in order to keep the fractured fragments in a reasonable alignment
by appropriate muscle contraction. This can be achieved with skin
traction (e.g. Femoral fractures in children) or skeletal traction
(e.g.Tibial traction for neck of femur fracture).
Slide 7
Skin traction involves application of a sustained pull on the
limb through weights suspended from a special bandage (tape or kit)
applied to the skin. In skeletal traction, a pin (e.g. Steinmans )
is inserted into the bone and traction is applied by weights
through a mechanism of pulleys. This traction may be xed (pull
against a xed point) or sliding (pull against an opposing force,
usually body weight).
Slide 8
Other common methods of immobilization are: Collar and cuff
sling for shoulder and arm fractures Neighbour or buddy strapping
for phalangeal and metacarpal fractures Commercial splints, e.g.
Thomas wrist splints Cast bracing, e.g. tibial plateau
fractures
Slide 9
Plaster immobilization may be discontinued after 4 to 6 weeks
in the upper limb and 10 to 12 weeks in the lower limb, if clinical
and radiological signs of union are present. Paediatric fractures
need much shorter periods of immobilization. For example, a young
child with a distal radius fracture may show signs of fracture
healing as early as 3 weeks and, therefore prolonged immobilization
is unnecessary.
Slide 10
Examples of fractures commonly treated with immobilization:
Minimally displaced fractures of the proximal humerus Undisplaced
fractures of the distal radius Stable compression fractures of the
dorsolumbar spine.
Slide 11
Operative treatment Operative treatment should never make the
patient worse! Both the surgeon and the patient should be aware of
the risks (infection, stiffness, nerve or vessel damage,
anaesthetic complications, etc.) associated with operative
intervention.
Slide 12
Operative treatment Common indications for operative
stabilization of a fracture include: Failure of conservative
treatment Early mobilization in order to prevent complications like
chest infection, bed sores, etc. Open fractures Polytrauma
Associated vascular injury requiring exploration Displaced
intra-articular fractures. Fractures of necessity; always
fixed.
Slide 13
Fracture of necessity; Some fracture in adults always fixed and
not treated conservatively. Neck of Femur fracture, Montagia
fracture, Galleazi fracture, Capitulum fracture, Talus
fracure.
Slide 14
Operative treatment The principles of open reduction and
internal xation of fractures are as follows: Anatomical reduction
Rigid internal xation Early rehabilitation.
Slide 15
Operative treatment Various internal xation devices are
available. Plates/screws/pins: displaced fractures of the shafts of
radius and ulna displaced intra-articular fractures of the tibial
plateau may require compression with plates and screws.
Slide 16
Screw fixation; unicondylar fr tibial pleatu, AC Joint
dislocation
Slide 17
Scaphoid fr, neck of femur fr. Intra capsular In young
Slide 18
Plates ; anatomical
Slide 19
DHS Extracapsular femoral neck fractures are often treated with
a dynamic hip screw This is a specially designed sliding device
that provides compression of the fracture site with weightbearing.
It permits early mobilization of elderly patients, thus reducing
the incidence of serious complications like pneumonia, urinary
tract infections, etc.
Slide 20
DHS
Slide 21
HEMI ARTHROPLASTY unipolar and bipolar
Slide 22
Intramedullary nails: These are metallic implants, which are
inserted into the medullary cavities of the long bones for fracture
stabilization. Displaced fractures of the shafts of the femur and
tibia are commonly treated with such devices. Ideally, an
intramedullary nail should be locked proximally and distally with
interlocking screws in order toachieve rotational and axial
stability. Important complications of intramedullary xation include
infection, fat embolism, delayed or non-union, joint stiffness,
etc.
Slide 23
Russel taylor nail; short nail; recon nail
Slide 24
External xator: An external xator is an external frame with
multiple pins that are inserted into the bone in order to achieve
stability. The pins are supported with clamps and rods to stabilize
the fracture. Nowadays, various modi cations of these frames (e.g.
Illizarovs ring xator) are available.
Slide 25
AO fixator ILIZROV fixator
Slide 26
Operative treatment Indications for external xation include:
Open tibial fractures, especially those associated with bone loss
Severely comminuted fractures of the radius Non-union requiring
bone transport.
Slide 27
Operative treatment Important complications associated with the
use of external xators are pin tract infection, joint stiffness,
malunion and non-union.
Slide 28
K-wires: Smooth K-wires may occasionally be used for
percutaneous xation of certain fractures. However, it should be
remembered that the use of these wires may cause pin-tract
infection, wire migration, nerve damage, etc.