Principles of Fracture Management

Widiyatmiko
Introduction

Orthopaedics is concerned
with bones, joints,
muscles, tendons and
nerves – the skeletal
system and all that makes
it move
Introduction
Scope : Subdivision :
• Congenital & developmental • Traumatology
abnormalities
• Infection & inflammation • Orthopaedi :
• Arthritis & rheumatic disorders 1. Adult Reconstruction
• Metabolic & endocrine 2. Oncology Orthopaedic
disorders
3. Pediatric Orthopaedic
• Tumours
• Sensory disturbance & muscle 4. Spine
weakness 5. Hand & Microsurgery
• Injury & mechanical 6. Sports Injury
derangement
 In Emergency Room…
• Assess all trauma patient for possibility of orthopaedic case!
• If the patient need operation  prepare as soon as possible!
1. Informed consent
2. Tell to fast at least 6 hours prior to op
3. Make IV line
4. Tetanus prophilactic
5. Antibiotic & analgetic
6. Blood check (SYSMEX for < 40 y.o, complete for > 40 y.o and < 14 y.o)
7. Urine check
8. Cross match & blood reservation in blood bank
9. EKG ( for > 40 y.o)
10. Chest X-Ray, with expertise for < 14 y.o
11. Complete the medical record ! (under resident supervision)
12. IPD or paediatric consultation ( for > 40 or < 14, sometimes no
need)
13. Anesthesiology consultation
General Principles of Fracture Treatment

1. First, Do No Harm
2. Base Treatment on Accurate Diagnosis
and Prognosis
3. Select Treatment with Specific Aims
4. Cooperate with the “ Laws of Nature “
5. Make Treatment Realistic and Practical
6. Select Treatment for You as an
Individual
Aphorism of Fracture Management

1. Think before you start. Are you treating

the patient? Or merely the x – ray?
2. Think before you reduce. Have you
worked out how to do it? And how to
hold your reduction?
3. Think before you hold. Is your splint
necessary? Is it harmful?
4. Think before you operate. Are you good
enough? Are your facilities good
enough?
What is fracture ?
• Fracture is a break or disruption in the
continuity of a bone.
Fracture divide in 2 types :
• Closed fracture
• Open fracture
 Fracture Description

 Anatomic location includes the name of the bone or the bones involved.

 Regional location – diaphysis ,metaphysis ,epiphysis; intraarticular or

extraarticular and physis.

 Directions of the fracture lines – transverse ,oblique and spiral.

 Conditions of the bone – comminution # ,pathological # ,incomplete #

,segmental # ,fracture with bone loss ,fracture with butterfly fragment
,stress # and avulsion #

 Extent – Fracture may complete or incomplete

 Relationship of the fracture fragments to each other – undisplaced or

displaced eg:translated,angulated,rotated,distracted,overriding and
impacted.
 Examination of The Affected Parts

 First We LOOK
 Then We FEEL
 Then We MOVE

• Neurological examination
• Diagnostic imaging
• Blood Test
• Synovial fluid analysis
• Bone biopsy
• Arthroscopy
• Electro diagnosis
Adult and Children Fracture
 Children Fracture
1. Fracture more common .
2. Stronger and more active periosteum .
3. More rapid fracture healing .
4. Special problems of diagnosis .
5. Spontaneous correction of certain residual
deformities .
6. Differences in complications .
7. Different emphasis on methods of treatment
8. Torn ligament and dislocation less common .
9. Less tolerance of major blood loss
 Adult Fracture
1. Fracture less common but more serious .
2. Weaker and less active periosteum .
3. Less rapid fracture healing .
4. Fewer problem of diagnosis .
5. No spontaneous correction of residual fracture
deformities .
6. Differences in complication .
7. Differences emphasis on methods of treatment.
8. Torn ligament and dislocations are more
common .
9. Better tolerance of major blood loss .
 CLOSED FRACTURE
The fracture is not exposed to the
external environment.

The soft tissue injury ranges from

minor to massive .

Closed soft tissue injury are commonly

graded by the methode of Tscherne
(grade 0 until grade 3 )
 TREATMENT
 Protection Alone without reduction or
immobilization
 Immobilization by External Splinting
without reduction
 Closed Reduction by Manipulation
Followed by Immobilization
 Closed Reduction by Continuous Traction
Followed by Immobilization
 Closed Reduction Followed by Functional
Fracture – Bracing
 TREATMENT

 Closed Reduction by manipulation

Followed by External Skeletal Fixation
 Closed reduction by Manipulation
Followed by Internal Fixation
 Open Reduction Followed by Internal
Skeletal Fixation
 Excision of a Fracture Fragment and
Replacement by an Endoprosthesis
 OPEN FRACTURE
• The fracture is exposed to the external
environment.
• The amount of soft tissue destruction
is related to the level of energy
imparted to the limb during the
traumatic episode.
• Describe with Gustillo-Anderson
grading system.
 OPEN (COMPOUND) FRACTURES

Goals

• Prevention of infection

• Healing of the fracture

• Restoration of function
 Steps in management

• ABC included resucitation and

immobilisation
• Assess neurovascular status of the limb
• Swab wound
• Photograph & Cover wound
• Tetanus prophylaxis
• Give IV antibiotics
• 1 . All open fractures are treated as emergencies.

• 2. Most studies demonstrate that cultures obtained on

admission are of little help. The most important cultures
are obtained after initial surgical debridement.

• 3. The basic prophylactic antibiotic should be a broad

spectrum cephalosporin.

• 4 . Generally, primary closure should not be formal but

may be considered in Grade I fractures only if adequate
debridement and irrigation have been done. Delayed
primary closure at 5 to 7 days is performed in Grade II
and Grade III injuries.
• 5. If there is any doubt about adequate
debridement, LEAVE THE WOUND OPEN!!!
THOROUGH DEBRIDEMENT AND
COPIOUS IRRIGATION is mandatory in the
initial treatment of all open fractures. For
Grade II and III fractures, generally use
pulsatile jet lavage. Exception for soft tissue
injuries which can compromise wound
coverage if there is swelling of the tissue. This
is not a reason to not clean the wound- a
toothbrush can be used on the exposed bone.
• 6. Rigid stabilization of fractures is
indicated in Grade III fractures and many
types of fractures in polytraumatized
patients. The type of fixation should be
determined by the resident and the staff
based on the nature of the injury and
bone involved.
WHAT IS POLYTRAUMA ?
 Objectives
Establish the principles for assessing the
patient with musculoskeletal injuries.
Establish treatment priorities.
Identify the importance of musculoskeletal
injuries in the multiply injured patient.
Emergency in Orthopaedic
• Emergency : trauma cases
- Life threatening
- Limb treatening
• 85 % of blunt trauma affect
musculoskeletal system
• Life saving before limb saving
Key Questions
• How do musculoskeletal injuries impact on
the primary survey?
• What are my priorities?
• What are my management principles?
Assessment of the Polytrauma Patient
Primary Survey
– A irway with cervical spine control
– B reathing
– C irculation with control of hemorrage
– D isability (neurological state)
– E xposure (take the patient clothes off)
 Primary survey management

The 3 S’s
Stop the bleeding!
Splint the extremity
Stabilize the pelvis
Primary Survey & Resuscitation

 Recognize and control hemorrhage

• Direct pressure
• Splint fractures
• Fluid resuscitation
BE AWARE OF REPERFUSION INJURY!
Primary Survey & Resuscitation

Adjuncts : Fracture immobilization

 Goals

• Hemorrhage control
• Pain relief
• Prevent further soft tissue injury
 Apply splint early, but avoid delay in resuscitation.

 Be careful in dislocation
Primary Survey & Resuscitation
Adjuncts : X-Rays
 Determinited by patient’s condition

 Obtain AP pelvis early if hemodynamically

abnormal and no obvious source of bleeding

Secondary Survey
• History
AMPLE

• From Head to toe examination

• Every orifice must be examined
• Don’t forget the back!
 Secondary Survey

Look
Feel
Listen
For What?
 For What?
Look Feel
 Deformity  Crepitus
 Pain  Skin flaps
 Tenderness  Neurologic
 Wound(s) deficit
 Pulses

Listen
Doppler signals
Bruit
Life- Threatening Injuries
 Major pelvic disruption with hemorrhage
 Major arterial hemorrhage
 Crush syndrome (rhabdomyolysis)
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
• Posterior pelvic structures disrupted
• Pelvis open : vessels, nerves,rectum, skin
• Mechanism of injury
– Motorcycle
– Pedestrian
– Crush
– Falls > 12 feet (3.6 meters)
Life Threatening Musculoskeletal
Trauma
Pelvic Trauma with Massive Bleeding
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Pelvic Wrapping
Life Threatening Musculoskeletal
Trauma
Main Arterial Rupture
1. Trauma
- sharp, blunt
2 Examination
- Artery pulse, Doppler
- Ankle / brachial index
3. Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint
Life Threatening Musculoskeletal
Trauma
Crush Syndrome
 Myoglobinuria
 Metabolic acidosis, ↑K,
↓Ca and coagulopathy
 Compartment syndrome
 IV fluids, alkalization of
urine
Limb- Threatening Injuries
 Open fracture and joint injuries
 Vascular injuries
 Compartment syndrome
 Neurologic injury
 What are my early concerns?

Vascular compromise
Open fractures
Limb Threatening
Musculoskeletal Trauma
Open Fractures

Apply appropriate splint

Cleanse / debride (now or later)
Consider time factor
Obtain orthopaedic consult
Limb Threatening
Musculoskeletal Trauma
Open Fractures

Classifying the injury

Gustilo’s classification (Gustilo et al, 1990)
Open Fracture grade 1
Open Fracture grade 2
Open Fracture grade 3A
Open Fracture grade 3B
Open Fracture
grade 3C
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
• Objectives :
- Prevention of infection
(sepsis/osteomyelitis)
- Promote bone healing
- Restoration of function
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
• 4 essentials are :
1. Wound irrigation & debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound coverage
Open Fracture
Complicated case
Not proper initial management
Limb Threatening Musculoskeletal
Trauma
Vascular Trauma & Traumatic Amputation

Reduce fracture(s)
Splint fracture(s)
Assess by Doppler
Obtain consult (time
is critical)
Consider
angiography
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

Management
• Muscle necrosis : 6 h
• Warm & Cold Ischemic
• Reimplatantation &
Revascularization
• Proper amputee
management!
Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome
• Fractures of the arm or leg  ischemia
• Infarcted muscles  fibrous tissue
(Volkmann’s ischemic contracture)
Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome
Clinical features
• Elbow, forearm bones, 1/3 prox.
of tibiae, multiple fractures of
the foot or hand, crush injuries &
circumferential burns
• Five Ps
• The presence of a pulse does not
exclude the diagnosis
• Be careful in unconscious patient
!
Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome

Treatment
• Decompression
• Open fasciotomi
Limb Threatening
Musculoskeletal Trauma Dislocations
• Displacement of bone from normal joint

• Location : hip, shoulder, elbow, finger, patella,

knee, ankle, acromioclavicular

• Sign : loss of normal shape &

loss of movement
Posterior Hip Dislocation
Neurologic Injury
 Due to fracture /dislocation
• Posterior shoulder : Axillary nerve
• Posterior hip : Sciatic nerve
 Recognize injury and immobilize
 Early orthopaedic consult
 Careful reduction, if possible → reassess
and splint
Limb Threatening
Musculoskeletal Trauma
Massive skin avulsion
Abdominal flap following
skin avulsion of the hand
Limb Threatening Musculoskeletal Trauma
Massive skin avulsion
‘Kelirumologi’ in Fracture Management
Pitfalls

 Occult injuries
 Occult blood loss
 Compartment syndrome
Case 1 : Male, 40 y.o
ICD 9-CM 79.63, 93.44
Summary
 Primary Survey : Identify life-threatening
Injuries
 Secondary Survey : Identify limb-
threatening injuries
 Mechanism of Injuries : History important
 Orthopaedic consult
 Early immobilization