This document discusses principles of fracture management. It defines fractures as breaks in bone continuity and classifies them as closed or open. For open fractures, initial management involves antibiotic prophylaxis, wound and fracture debridement, and early wound cover or stabilization. Closed fracture management focuses on reduction, maintaining reduction through splinting, casting or fixation, and rehabilitation. Complications of different fixation methods like skeletal traction are also reviewed. The main goals of fracture treatment are outlined as reduction, maintaining reduction, and rehabilitation.

1. Principles of
Fractures management
Mohammed Hassan Hilow
4th year med student at Kufa university
Mohassen223@gmail.com

2. A fracture is a break in the structural continuity of
bone. It may be no more than a crack, a crushing
or a splintering of the cortex .
Fracture
Closed fracture:
the overlying skin remains intact.
Open fractures:
An open fracture is a fracture that communicates
with an overlying break in the skin. also known
as a compound fracture) AAOS 2009

3. Treat the whole patient, not only the
fracture.

4. A -Airwaywith cervical spine protection.
B -Breathing.
C -Circulationwith haemorrhage control.
D -Disabilityor neurological status.
E-Exposure and Environment.
ABCDE

5. OPEN vs. CLOSED
• Reduction
• Maintain reduction
• Rehabilitation.
Three main objectives

6. IIIC
There is an arterial injury which needs to be repaired,
regardless of the amount of other soft-tissue damage.
Openfractures

8. Initial management
A. Antibiotic prophylaxis
B. Urgent wound and fracture
debridement
C. Early definitive wound cover
D. Stabilization of the fracture
Openfractures

9. A. Antibioticprophylaxis

10. B. Urgent wound and fracture debridement
• Wound excision& extension
• Examinationof the fracture
surfaces
• Removal of devitalized tissue
• Nerves and tendons
“As a general rule it is best to
leave cut nerves and tendons
alone”

11. Earlydefinitivewoundcover
Wound closure
A small, uncontaminated wound
in a type I or II fracture may be
sutured (after debridement),
second look at surgery….
definite fracture covering should
be done ideally within 48–72
hours, and not later than 5–7
days

12. The method of fixation selected depends on
• The degree of contamination,
• Time from injury to operation and
• Amount of soft-tissue damage.
Stabilizationof the fracture
open fractures of all types can be treated as for a closed injury?
If there is no obvious contamination and definitive
wound cover can be achieved at the time of
debridement

13. The External fixator vs. Internal fixation
(1) the delay towound coveris less than 7 days;
(2) wound contamination is not visible; and
(3) internal fixation can control the fracture as well as the
external fixator
When to change external
fixation to internal fixation ?

15. Closed fracture

17. • Reduce
• Maintain reduction
• Rehabilitate.
Three main objectives

18. Reduction
Do all fractures need reduction ?

19. • Function
• Mobility
• Union
• Neurovascular compromise
• Cosmesis
Reduction is important if

20. Situations in which reduction is unnecessary:
(1)when thereis little or nodisplacement;
(2) Whendisplacement does not initially matter (e.g. in some fracturesofthe
clavicle); and
(3) when reductionis unlikely to succeed(e.g. with compression fracturesof
the vertebrae).
Could reduction be unnecessary ?

21. Open Vs. Closed
Reduction
Closed manipulation is suitable forall minimally displaced
fractures,formostfracturesin children and forfracturesthat
arelikely tobestable afterreduction.
(1) The distal part of the limb is pulled
in the line of the bone;
(2) As the fragments disengage, they
are repositioned (by reversing the
original direction of force if this can be
deduced); and
(3) Alignment is adjusted in each plane.

22. Open Vs. Closed
Open reduction
Operative reduction under direct
vision is indicated:
(1) when closed reduction fails
(2) when there is a large articular
fragment that needs accurate
positioning;
(3) for avulsion fractures
(4) when an operation is needed
for associated injuries (e.g. arterial
damage).

24. Maintaining fracture reduction
Stability is achieved by one of the following
techniques:
1 Intrinsic stability.
2 External splintage.
3 Internal fixation.

25. Some fractures require no additional stabilization
Intrinsic stability

26. External splintage
How accurately the fracture needs to be held??
(1)Cast splintage;
(2) Sustained traction;
(3) Functional bracing;
(4) Internal fixation;
(5) External fixation.

27. Cast splintage
POP vs. New types
Advantages
• light in weight, but very strong
• patient may be able to bear weight on
an unprotected cast
• nursing and moving a patient easer
• waterproof
Disadvantages.
• they cannot be readily molded
and are more expensive.

28. Sustained traction
Types Based On Method Of Application
1. Skin traction
The traction force is applied over a large
area of skin
2. Skeletal traction.
Applied directly to the bone either by a pin
or wire through the
bone.
3. Traction by gravity
Applies only to upper limb injuries.
Particularly useful for spiral fractures of long-bone shafts,
which are easily displaced by muscle contraction

29. Types Based On Mechanism
1.Fixed traction,
e.g. Thomas’s splint
2.Balanced traction ,
e.g Braun’s frame for
the tibia
3.Combination of the two.

30. • Allergic reactions to adhesive
• Excortication of skin
• Pressure sores around the malleoli
and over the tendo calcaneus
• Common peroneal nerve palsy
• infection into the bone
• Incorrect placement of the pin or wire may-
o Allow the pin or wire to cut out of the bone causing pain and the
failure of the traction system
o Make control of rotation of the limb difficult
o Make the application of splints difficult
o Result in uneven pull being applied to the ends of the pin or wire
and thus cause the pin or wire to move in the bone
• Distraction at the fracture site
• Ligamentous damage if a large traction force is applied through a joint
for a prolonged period of time
• Damage to epiphyseal growth plates when used in children
• Depressed Scars
Complications of Skeletal Traction
Complications of Skin traction

31. Removal Of Traction
• Elbow fracture with olecranon pin 3weeks
• Tibial fracture with calcaneal pin 3-6 weeks
• Trochanteric fracture of femur 6weeks
• Femoral shaft fracture
o with application of cast brace and 6 weeks
partial weight bearing
o without external support and 12 weeks
partial weight bearing

32. (3) Functional bracing;
(4) Internal fixation;
(5) External fixation

33. Rehabilitate.
This begins immediately after the primarytreatment. Thelimb is moved and used as muchas the method of fixation
allows
This helps to stimulate union and to prevent joint stiffness. Internal fixation, if secure, has
great advantages in this respect.
Whensplintage is discontinued, a furtherperiod of exercises or physiotherapy is often necessary before full joint
functionis restored

35. “The secret of success is constancy to purpose”
© Benjamin Disraeli

36. Thank you