5.definitive treatment of fractures
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5.definitive treatment of fractures

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Orthopaedic lectures for final MBBS by Dr G.S. Edirisinghe, consultant orthopaedic surgeon, Teaching hospital Kandy

Orthopaedic lectures for final MBBS by Dr G.S. Edirisinghe, consultant orthopaedic surgeon, Teaching hospital Kandy

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5.definitive treatment of fractures 5.definitive treatment of fractures Document Transcript

  • 1 Handout 5 Definitive treatment of fractures Stabilize the general condition Replace lost blood Take care in pelvic fractures as the blood loss can be very heavy and not visible. Large vein cannula Objectives: Let bone heal in a good position, function and cosmesis must be unimpaired Return patient back to society and recreation shortest possible time with least expense. Closed and open methods: Closed methods: Manipulate and reduce ( R ) Apply device to hold reduction ( I ) Rehabilitate ( R ) Reduction: Open or close Under anaesthesia or pain relief Sooner the better Under anaesthesia, apply traction, Reverse the mechanism of fracture Align the controllable fragment ( distal fragment ) with the fragment that cannot be controlled: Reduction depend on the soft tissue linkage Immobilization: Using traction, External devices or internal devices Rehabilitation: 4 Basic methods are available to achieve this. You will see these 4 methods used in the ward rounds. 1. Closed reduction, Traction ( used mainly for femoral fractures of children ) 2. Closed reduction, POP cast – a very common, less expensive method 3. Open reduction, Internal fixation using internal metal devices – now done more and more 4. Open reduction and External fixation- used almost always for open fractures Medical therapy: The goal in managing fractures is to ensure that the involved limb segment, when healed, has returned to its maximal possible function. This is accomplished by obtaining and subsequently maintaining a reduction of the fracture
  • 2 with a technique of immobilization, which allows the fracture to heal and, at the same time, provide the patient with functional aftercare. Either nonoperative or surgical means may be used. Nonoperative therapy consists of casting and traction, which includes skin traction and skeletal traction. Closed reduction 1. MUA+POP 2. Traction- for <2 yrs / <18kg → Gallows traction in femur #, heals by 2/52 3. Bracing/ sling: clavicle #, surgical neck of humerus 1 . Casting Closed reduction should be performed initially for any fracture that is displaced, shortened, or angulated. Closed reduction is achieved by applying traction to the long axis of the injured limb and then reversing the mechanism of injury/fracture followed by immobilization through casting or splinting. Splints and casts can be made from fiberglass or plaster of Paris. Barriers to accomplishing reduction include soft tissue interposition and hematoma formation that create tension in the soft tissues. Closed reduction is contraindicated under the following conditions 1. 2. 3. 4. 5. If significant displacement is unappreciable If displacement exists but is not relevant (eg, humeral shaft fracture) If reduction is impossible (severely comminuted fracture) If the reduction, when achieved, cannot be maintained If the fracture has been produced by traction forces (eg, displaced patellar fracture) POP: Plaster Of Paris ( calcium sulphate hemihydrate ) is made by heating Gypsum ( Calcium Sulphate) ) Was discovered by a Dutch Military Surgeon, Antonius Mathieson in 1852 Muslin cloth rolls, stiffened by starch, is impregnated with dehydrated gypsum (hemihydrate of calcium sulfate) These rolls are immersed in water for a few seconds prior to application CaSO4 . ½ H2O + H2O → CaSO4.2H2O and heat is liberated POP then becomes a homogenous, rocklike mass in 36 hr POP splints, called back slabs also are used to immobilize fractures. Usually 15 layers of POP is used to make a POP back slab. They are used in first aid to immobilize fractures , and in the immediate post operative period.
  • 3 Fiberglass casts (scotch cast/3M: but expensive) are available now. They are light weight, long wearing, radiolucent, can get wet, weight bearing can take place Immediately after application on these casts as they are very strong Rubber gloves are mandatory in application of scotch casts Expensive NEVER applied in the acute setting 2. TRACTION For hundreds of years, traction has been used for the management of fractures and dislocations that are not able to be treated by casting. With the advancement of orthopedic technology and techniques, traction is rarely used today. Two types of traction exist: skin traction and skeletal traction. In skin traction, traction tapes are attached to the skin of the limb segment below the fracture. When applying skin traction, or Buck traction, usually 10% of the patient's body weight (up to 10 lbs) is recommended. At weights greater than 10 lbs, superficial skin layers are disrupted and irritated. Because most of the forces created by skin traction are lost and dissipated in the soft tissue structures, skin traction is rarely used as definitive therapy in adults; rather, it is commonly used temporarily until definitive therapy is achieved. For example, skin traction is used preoperatively in individuals who have sustained a femoral neck fracture. The traction is maintained until the patient is taken to the operating room for ORIF or hemiarthroplasty. In skeletal traction, a pin (eg, Steinmann pin) is placed through a bone distal to the fracture. Weights are applied to this pin, and the patient is placed in an apparatus to facilitate traction and nursing care. Skeletal traction is most commonly used in femur fractures: A pin is placed in the distal femur (see Image 4) or proximal tibia 1-2 cm posterior to the tibial tuberosity. Once the pin is placed, a Thomas splint is used to achieve balanced suspension. Skin Traction Maximum 8 lbs. Don’t shave the skin Pad the malleoli proximally Skeletal traction: Introduced by Fritz Steinmann Olecranon, supracondylar region of the femur, proximal tibia, Os calcis Charnley traction unit: Prevents equinus Popliteal nerve and calf muscles are protected. External rotation of the femur is protected. Tendo-calcaneous is protected from pressure. Comfortable
  • 4 Fractures of the tibia and ipsilateral femur can be managed in the same manner 3. Internal fixation of fractures: Sir Arbothnot Lane used screws to fix an oblique fracture of tibia in 1907. Then he used plates, initially made up of German silver or steel Initial plates were very flimsy; they were made small to avoid reactions. Sherman, in USA made Thicker, more strong plates. The 316L stainless steel is standard for surgical implants. (Nickel, chromium, manganese, molybdenum, silicon, and carbon also added to steel in varying amounts) Titanium and Titanium Alloys also are used now for implants Cobalt-Chromium Alloys- this has been a material of choice for the manufacture of stems for hip prostheses. Commercially pure titanium can be used in patients who are sensitive to nickel and chromium. Veneble and Stuck of San Antonio invented Vitallium, this is a Non-metal alloy. Surgical therapy for fractures : In 1958, the Association for the Study of Internal Fixation (ASIF), in Switzerland, created 4 treatment goals in terms of surgical fracture management (Muller, 1990). They have not changed today and are as follows. 1. Anatomic reduction of the fracture fragments: For the diaphysis, anatomical alignment assuring that length, angulation, and rotation are corrected is required, whereas intra-articular fractures demand an anatomic reduction of all fragments. 2. Stable internal fixation to fulfill biomechanical demands 3. Preservation of blood supply to the injured area of the extremity 4. Active pain-free mobilization of adjacent muscles and joints to prevent the development of fracture disease Open reduction and internal fixation Indications Fractures that 1. cannot be reduced except by operation. 2. inherently unstable and prone to re-displace after reduction (e.g. mid-shaft fractures of the forearm and some displaced ankle fractures). Also included are those fractures liable to be pulled apart by muscle action (e.g. transverse fracture of the patella or olecranon).
  • 5 3. unite poorly and slowly, principally fractures of the femoral neck. 4. Pathological fractures in which bone disease may prevent healing. 5. Multiple fractures where early fixation (by either internal or external fixation) reduces the risk of general complications and late multisystem organ failure 6. Fractures in patients who present nursing difficulties (paraplegics, those with multiple injuries and the very elderly). The objectives of ORIF include adequately exposing the fracture site and obtaining a reduction of the fracture. Once a reduction is achieved, it must be stabilized and maintained. Today almost all Orthopaedic surgeons around the world adhere to these principles, which are known as AO Method. Various devices are used to perform Internal fixation. 1. Suture (in small children) 2. Pins+wires 3. Screws 4. Plates+ screws 5. Intramedullary nails 6. Prosthesis Kirschner wires Kirschner wires, or K-wires, are commonly used for temporary and definitive treatment of fractures. However, K-wires resist only changes in alignment. They do not resist rotation and have poor resistance to torque and bending forces. They are commonly used as adjunctive fixation for screws or plates and screws especially involving fractures around joints. When K-wires are used as the sole form of fixation, casting or splinting is used in conjunction. They can be placed percutaneously or through a mini-open mechanism. K-wire fixation “is adequate for small fragments in metaphyseal and epiphyseal regions, especially in fractures of the distal foot, wrist, and hand, such as Colles fractures, and in displaced metacarpal and phalangeal fractures after closed reduction”. K-wires are commonly used as adjunctive therapy for many fractures such as patellar fractures, proximal humerus fractures, olecranon fractures, and calcaneus fractures. Plates and screws Plate designs vary depending on the anatomic region and size of the bone the plate is used on, and 4 main designs exist: buttress plates, compression plates, neutralizing plates, and bridge plates . All plates should be applied with minimal stripping of the soft tissue. Buttress plates counteract compression and shear forces that commonly occur with fractures involving the metaphysis and epiphysis and are commonly used with interfragmentary screw fixation. The plate is always fixed to the larger main fracture fragment but does not necessarily require fixation through the small fragment, as
  • 6 the plate buttresses the small fragment into the larger fragment. This function requires appropriate plate contouring to provide adequate fixation and support. They are commonly used around joints to support intra-articular fractures. Compression plates counteract bending, shear, and torsion forces by providing compression across the fracture site through the use of the eccentrically loaded holes in the plate. They are commonly used in long bones, especially the fibula, radius, and ulna, and in nonunion or malunion surgery. Neutralization plates are used in combination with interfragmentary screw fixation. The interfragmentary compression screws provide compression at the fracture site. This plate function neutralizes torsional, bending, and shear forces on the lag screw fixation and increases the stability of the construct. Neutralization plates are commonly used for fractures involving the fibula, radius and ulna, and humerus. Bridge plates are useful in the management of multifragmented diaphyseal and metaphyseal fractures. Achieving adequate reduction and stability without disrupting the soft tissue attachments to the bone fragments may be difficult and requires skill in the use of indirect reduction techniques. Plates and screws are commonly used in the management of articular fractures. This use demands an anatomic reduction of the fracture fragments. This allows for early ROM and the use of muscles and joints in the injured extremity. Plates provide strength and stability to neutralize the forces on the injured limb for a functional postoperative aftercare (see Images 7-8). Intramedullary nailing : Hey Groves inserted the first IM nail during the First World War, but was Defeated by inadequacies of metal. Gerhardt Kuntscher rediscovered. Now the commonly used femoral Intramedullary nail is named after him. The use of Intramedullary nails over the past half century has been widely accepted. Intramedullary nails operate like an internal splint that shares the load with the bone. Intramedullary nails can be flexible or rigid, locked or unlocked, and the intramedullary canal can be reamed or unreamed. Locked intramedullary nails provide sufficient stability to maintain alignment and length, and limit rotation. Ideally, the intramedullary nail allows for compressive forces at the fracture site, which stimulates bone healing. Intramedullary nails are commonly used for femoral shaft fractures (see Image 9); tibial shaft fractures; and, occasionally, humeral shaft fractures. Advantages of intramedullary nails include minimally invasive procedures, early postoperative ambulation, and early range of movement ROM. 4. External fixation of fractures:
  • 7 In 1907 in Europe, Alvin Lambotte developed external fixation for management of fractures. External fixation provides stabilization of a fracture at a distance from the fracture site without interfering with the soft tissue structures that are near the fracture. This provides stability for the extremity and maintains length, alignment, and rotation without requiring casting. It also allows for inspection of the soft tissue structures vital for fracture healing. Indications for external fixation (temporarily or as definitive care) are as follows: 1. Open fractures that have significant soft tissue disruption (eg, type II or III open fractures) 2. Soft tissue injury (eg, burns): wounds can be left open for inspection, dressing, or definitive coverage 3. Acetabular fractures 4. Pelvic fractures: which often cannot be controlled quickly by any other method 5. Severely comminuted and unstable fractures 6. Fractures that are associated with bony deficits/ neurovascular damage 7. Limb-lengthening procedures 8. Fractures associated with infection or nonunion Bone transport procedures Arthrodesis Helpful in the management of fractures associated with nerve, vascular damage, open wounds, massive soft tissue burns. Used for a short period till the skin heals, then converted to pop. Advantages : 1. Less damage to blood supply of bone 2. Les damage to soft tissue cover 3. Useful for stabilizing open fractures 4. Adjustments possible without surgery 5. Good option in the presence of bone/ soft tissue infection 6. Requires less skill and experience Disadvantages : 1. Pis and wires penetrate tissue – infection 2. Restricted joint motion 3. Pin tract complications 4. Cumbersoe, not well tolerated 5. Limited rigidity – eg in femur Choice of metals for surgical implants Ideal implant material Inert, non-toxic to the body, absolutely corrosion proof. can be easily worked, capable of being wrought in a variety of shapes without expensive manufacturing techniques.
  • 8 It must have great strength and resistance to fatigue. Stainless steel, corrodable Vitallium (cobalt. Chromium and molybdenum alloy) mechanically inferior. Titanium, most inert, easily worked. The choice between closed methods and open methods. Either one or the other is recognized as the most satisfactory treatment and therefore indicated. As a rule, if open reduction is performed, internal fixation should be applied. ABSOLUTE INDICATIONS 1. When closed methods fail/ or going to fail: adult forearm # 2. Displaced intra articular fractures/ when 100% anatomical reduction is needed 3. Major avulsion fractures: patellar, olecranon # 4. Nonunions/malunion: may need bone graft 5. Fracture with vascular/nerve injury which needs repair: supracondyler # with brachila artery damage. Fix the bone 1st before vessels 6. Type III and IV epiphyseal fractures. 7. Replantation of extremities RELATIVE INDICATIONS 1. Polytrauma pt: e.g. bladder, bowel injury 2. Multiple fractures: as it can minimize plasters 3. Pathological fractures: can biopsy same time also 4. Pt who needs ICU care/ To improve nursing care (brain injured patients,) 5. Pt who needs early mobilization: young high performing athletes, elderly/ To reduce mortality or morbidity from prolonged cast or bed immobilization, e.g. NOF # in the elderly. So once after heal the # they can go back to work without joint stiffness or muscle waste 6. Delayed union 7. Loss of reduction following closed methods 8. Fractures in which closed methods are doomed to fail Galeazzi, Monteggia, NOF # QUESTIONABLE INDICATIONS Fractures accompanying blood vessel and nerve repair The additional surgical trauma operating time required for Open Reduction and Internal Fixation increase the incidence of post operative wound infection Stabilization better applied by traction, external fixation Open fractures:
  • 9 Some investigators report that open Fractures must be fixed rigidly Stabilization prevents infection Must do a good excision of dead and contaminated tissues Insert the metal device if possible through a separate exposure. Cosmetic considerations Economic considerations CONTRA INDICATIONS 1. Active infection or osteomyelitis: even abscess/ pneumonia→ hematogenous spread 2. Weak or soft bone: extreme osteoporosis 3. Contaminated compound fractures: due to risk of infection. So good wound toilet is needed prior fixation 4. Poor quality surrounding soft tissue: infected eczema 5. Contraindications to surgery because of poor general conditions 6. Fragments are small 7. Undisplased fractures 8. No consent ADVANTAGES OF Open Reduction AND Internal Fixation 1. 100% anatomical reduction 2. Early mobilization 3. Minimize hospital stay DISADVANTAGES OF Open Reduction AND Internal Fixation 1. A closed fracture is converted to an open Fracture. 2. Infection risk: breech ext barrier, leave metal inside 3. May delay healing because of stripping of the periosteum. 4. Requires longer GA 5. Requires blood transfusions with associated risk of HIV and Hep B infection. 6. Implant failure 7. Requires qualified personnel 8. Requires expensive instrumentation and prosthesis 9. Need a second operation for metal removal 10. Scar Management of open fractures The goals of treatment of open fractures are to prevent infection, to allow the fracture to heal, and to restore function in the injured limb. Once initial assessment, evaluation, and management of any life-threatening injury are completed, the open fracture is managed. Hemostasis should be obtained, followed by antibiotic administration.
  • 10 Cefazolin is adequate for type I and type II injuries. If the wound is severely contaminated (type III), an aminoglycoside can be added (eg, gentamycin or tobramycin). If the injury is a “barnyard injury” and if Clostridium perfringens prophylaxis is required, penicillin is added. Tetanus prophylaxis and immunization should be administered to patients who have not been previously immunized. Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory. For type II and type III injuries, serial I&D is recommended every 24-48 hours after the initial debridement until a clean surgical wound is assured. The wound is closed when it is clean. Antibiotics are generally given for 2 days after final I&D. Management of the fracture depends on the site of injury and type of open fracture; however, the fracture is stabilized with external or internal fixation. If soft tissue coverage is inadequate, soft tissue transfers or free flaps are performed when the wound is clean and the fracture reduced and stabilized definitively. Preoperative details: Detecting and adequately addressing all other injuries, along with other co morbidities and preexisting medical conditions, is essential. If patients have multiple medical problems, consult an internal medicine specialist before performing any operative intervention. Prophylactic antibiotics (Cefazolin, 1 g) should be administered. If the patient is allergic to penicillin, clindamycin can be administered. Patients with open fractures should be given appropriate prophylaxis (see Management of open fractures). Intraoperative details: C-arm fluoroscopy is valuable and often necessary in the operating room to provide for and evaluate the results of internal fixation prior to the patient leaving the operating room. Alternatively, portable radiography can be used if multiple radiographic images are not anticipated to be necessary. Postoperative details: Postoperatively, appropriate wound care and suture or staple removal are performed as directed by the physician. Depending on the type of fracture sustained, patients may be immobilized in a splint or cast. Postoperatively, patients are examined at follow-up visits usually within 1-2 weeks of their surgery and periodically until the fracture has healed and function has returned. Weightbearing status is dependent upon fracture or osteosynthesis construct stability. With lower-extremity fractures, weight bearing is usually restricted, but early ROM is encouraged. Rehabilitation: Focus on restoration of function Helps patients to adapt to their environment Goals of rehabilitation: Restore function of the part Prevent additional disability Improve unaffected systems
  • 11 Follow-up care: The timetable for follow-up visits varies depending on the nature of the injury. All patients must be monitored closely for potential complications (see Complications). At the time of discharge after initial care of the fracture, the patient should be made aware of all of the follow-up requirements specified by the treating physician. Consultation with rehabilitation specialists can be useful in helping inpatients to ambulate with the aid of crutches or a walker and, ultimately, to decrease postoperative morbidity and expedite their discharge planning. Consultation with rehabilitation specialists is not essential for some outpatients to regain function. However, rehabilitation services can be invaluable for many individuals in regaining their ROM and strength once the fracture has healed. The need for physiotherapy depends on the nature of the injury and the motivation, education level, and abilities of the patient. Physiotherapists aid in helping patients to recover from joint stiffness and to maintain and restore ROM. They provide appropriate guidance with respect to exercises and activities that aid in the healing process. Prolonged immobilization is detrimental