basic fracture management

1. Basic principles of fracture
management
Nyiiro Francis MBchB, MMed/Ortho,
FCS(ECSA), Fellow Pediatric Ortho (uoT)
Consultant Orthopaedic Surgeon

2. CASE
• Middle aged man picked by police from the
middle of the road, reportedly knocked by
speeding vehicle.
• Unable to walk, leg deformed, in a lot of pain
and extremities cold
• Pulse 100 b/min, Respiratory rate 30 b/min

3. What is a fracture
• Cracking or breaking of hard object or material
• Continuity of bone is broken

4. What we need to achieve
• Able to identify an injured patient
• Identify life threatening conditions
• Identify specific injuries
• Emergency treatment of injured patient
• Initial management of injured patient

5. Mechanism- remember process
leading to fracture
• Traumatic –(high)
• Pathological (low energy)-tumor, metabolic
bone disease, osteopenia, infection
• Stress fractures – repetitive mechanic loading

6. Clinical features of fractures
• Pain /tenderness
• Loss of function- skin, muscles and bones
• Deformity/leg length discrepancy
• Abnormal mobility and crepitus
• Altered neurovascular status

7. Initial management
• ABCDEs
• Limb – attend to neurovascular status
• Rule out other fractures or injuries
• Rule out open fractures
• Take an SAMPLE history- symptoms, allergies, medical
history, past history, last meal, events sorrounding
injury
• Splint fracture – pain control, reduce tissue damage,
blood loss
• Analgesia
• X-ray rule of 2 pre- and post- operative

8. Radiographic description of fractures-
rule of 2s
• 2 sides: bilateral
• 2 views: AP/Lateral
• 2 joints: above and below
• 2 times: before and after reduction

9. Radiographic description of fractures
• Patient identification
• Identify views
• Open or closed: air in
soft tissue-
open#/infection
• site: site, thirds,
metaphyseal,
diaphyseal or intra-
articular.

10. type
• Spiral: rotational force, low energy
• Oblique: angular or rotational force
• Transverse: direct force, high energy
• Comminuted: (>2pcs) – direct force, high
energy

13. Soft tissue
• Cast/splint
• Calcification
• Gas /air
• Foreign bodies

14. Displacement –distal wrt proximal
• Aposition/translation
• Angulation
• Rotation
• shortening

16. reduction
• Is reduction necessary- may not be for #fibula,
clavicle, compression vert #
• Reduce when amount displacement
unacceptable
• Imperfect apposition may be acceptable but
not imperfect alignment
• Closed when possible

17. Indication for open reduction-NO CAST
• N - non union
• O – open fracture
• C – neurovascular compromise
• A – articular fracture
• S- Salter Harris iii, iv v
• T - polytrauma

18. Stabilization
• Displaced fractures
• Potential to displace

19. External fixation
• Splints/tape
• Casts
• Traction
• External fixator

20. Internal fixation
• Percutaneous pinning
• Extra medullary fixation
• Intra medullary fixation

21. Rehabilitation
• Avoid joint stiffness
• Isometric exercises to avoid muscle atrophy
• ROM for adjacent joints
• CPM especially intra-articular fracture
• Muscle strengthening exercises
• Evaluate # healing with x-ray

22. Open fractures
• Emergency! Fracture communicates with skin
surface.
• Examine fracture carefully to classify

24. Initial treatment
• Do not reduce unless neurovascular compromise
• Remove gross debrise
• All open fractures contaminated!
• Administer tetanus vaccine/booster
• Start antibiotics
• Splint
• NPO prepare for OR
• Irrigation and debridement
• Reduction and stabilization

25. Initial treatment
• Go to OR within 6 hrs preferrably
• Re-exam for possible repeat I&D within 48 hrs.

27. Complications of open fractures
• Osteomyelitis
• Soft tissue damage
• Neurovascular injury
• Blood loss
• Non union