PRINCIPLES OF FRACTURE/ DISLOCATIONS MANAGEMENT

1. PRINCIPLES OF FRACTURE/ DISLOCATIONS MANAGEMENT DR. SAVITH V SHETTY DEPT. OF ORTHOPAEDICS

2. INVESTIGATIONS RADIOGRAPHY Rule of two’s : Two views Two Joints Two Limbs Two Injuries Two Occasions

3. Description Location of the fracture – Epiphysis, Metaphysis or Diaphysis. Pattern of fracture Alignment, Angulation, Displacement, Rotation Comminution Bone Condition Joint involvement Soft tissue swelling

4. SPECIAL IMAGING • C.T SCAN Evaluation of injuries to the spine, complex intra articular, acetabular and calcaneal fractures. • MRI SCAN Spinal cord injuries, ligamentous injuries and soft tissue injuries.

5. Treatment • The treatment of fractures may be divided into three phases: Emergency care Definitive treatment Rehabilitation.

6. Emergency Care Splinting "Splint them where they lie." Advantages: 1. Further soft-tissue injury (especially to nerves and vessels) may be averted and, most importantly, closed fractures are saved from becoming open. 2. Immobilization relieves pain. 3. Splinting may well lower the incidence of clinical fat embolism and shock. 4. Patient transportation and radiographic studies are facilitated.

7. Types of Splints Improvised Splints Almost anything rigid can be pressed into service - walking sticks, umbrellas, slats of wood-padded by almost any material that is soft, folded newspapers or magazines and when all else fails, bandaging the lower extremities together or fixing the arm to the trunk will help.

8. Conventional Splints Universal Splints Universal arm and leg splints, which are made of aluminum and prefabricated to fit the leg or upper limb. Cramer Wire Splints Resemble miniature ladders with malleable metal uprights and wire rungs. They can be bent into appropriate shapes, padded, and bandaged to the extremities. They do not appreciably interfere with radiographic examinations and are most useful.

9. Thomas Splints Used for splinting lower limb fractures. Traction can be given over this splint. Inflatable splints

10. Structural aluminum malleable (SAM) splint Thin strips of soft aluminum coated with polyvinyl. When folded longitudinally (the "structural bend"), these floppy, malleable strips change as if by magic to rigid members.

11. Definitive Treatment of Closed Fractures Objectives of the treatment to allow the bone to heal in such a position that the function and cosmesis of the extremity are unimpaired to return patients to their vocation and avocations in the shortest possible time with the least expense. Treatment consists of : Reduction Retention Rehabilitation

12. Reduction Two methods : Closed reduction To achieve a reduction, the following steps usually are advised: (1) apply traction in the long axis of the limb (2) reverse the mechanism that produced the fracture (3) align the fragment that can be controlled with the one that cannot. Open reduction Reduction of the fracture is done under direct vision by surgically opening the fracture site.

13. Indications of Open Reduction • Failure of closed reduction - difficulty controlling fragments or soft tissue inter position • Intra articular fractures that require accurate positioning. • Traction fractures in which the fractures are held apart. • Type 3 or 4 Epiphyseal injuries. • Multiple fractures • Pathological fractures • to avoid prolonged bed rest

14. Hold Reduction • METHODS Continuous Traction Cast Splintage Functional Bracing Internal Fixation External Fixation

15. Continuous Traction Continuous traction may be applied through Skin Traction Traction is applied over a large area of the skin Maximum weight that can be applied is 5kg. Two types : Adhesive and Non Adhesive. Skeletal Traction Traction is given through a metal pin driven through the bone. Indicated when more than 5kg traction weight is required. Pins used are Steinman pin, Denham pin and K wire. Traction by Gravity In fractures of the humerus a very light "hanging" cast is applied the combined weight of the upper extremity and cast applies traction to the humeral fracture

16. Cast Splintage • Plaster of Paris Casts The plaster-of-Paris bandage consists of a roll of muslin stiffened by dextrose or starch and impregnated with the hemihydrate of calcium sulfate. When water is added, the calcium sulfate takes up its water of crystallization (CaSO4 H2O + H2O = CaSO4 2H2O + heat). This is an exothermic reaction, and after a few minutes the plaster-of-Paris becomes a homogeneous, rocklike mass.

17. Fiberglass Casts • a variety of knitted materials-cotton, rayon, and fiberglass-have been impregnated with polyurethane pre-polymer, which when soaked in water cures to form a light, durable, material that is radiolucent.

18. Complications • Tight cast Due to tight application or swelling of limb May lead to vascular compression and compartment syndrome. Essential to split the cast and ease it open. • Pressure sores Cast may press upon the skin on a bony prominence Requires immediate inspection through window in the cast. • Skin abrasion or laceration commonly occur during removal of cast. • Loose cast due to subsidence of swelling.

19. Functional Bracing • Segments of cast are applied only over the shaft of the bones ,leaving the joints free. The cast segments are connected by metal or plastic hinges. • Applied only when the fracture is beginning to unite. • Advantages- joint movements are less restricted while fracture remains stable.

20. Internal fixation • Internal fixation holds the fracture securely so that movements can begin at once. • Types • Inter fragmentary screws - partially threaded screws exert a compression or lag effect. 2. Wires - cerclage and tension band loops of wire are passed around two bone fragments and tightened to obtain compression. Commonly used in patellar and olecranon fractures.

21. Plates and Screws • Useful for treating metaphyseal and diaphyseal fractures of long bones. • Types Neutralisation- used to bridge a fracture and supplement the effect of interfragmentary screws. resists torque and shortening. Compression- compression at the fracture is obtained by use of dynamic compression plate or by an external compression device.

22. Buttressing - plate props up the overhang of the expanded metaphysis, negates compression and shear forces. plate is anchored to the main stable fragment but not necessarily the fragment it is supporting. • Tension bands - plate is placed on the tensile surface of the bone and converts the distractional forces to compressional forces .

23. Used to treat Long bone fractures. Nail is inserted into the Medullary canal and interlocking screws are introduced which transfix the bone cortices and the nail proximally and distally. Intramedullary nails

24. Complications • Infection : common cause for chronic Osteomyelitis. • Non Union : improper fixation, stripping of soft tissue and loss of local blood supply. • Implant failure: metal implants are subject to fatique and it is important that excess stress is avoided till bone union occurs. • Refracture : important not to remove metal implants early.

25. External Fixation • External fixators allow stabilization of a fracture at a distance from the fracture site without increasing soft-tissue damage. • soft-tissue wounds can be easily inspected and treated, and allows early mobilization and activity. • Indications Compound Fractures Severely Comminuted and unstable fracture. Associated with nerve or vessel damage. Fractures of the Pelvis. Infected Fractures. Severe Multiple Injuries

26. Rehabilitation • Prevention of Oedema Elevation of the limb Active exercises • Assisted movements Forced movements should never be done Continuous Passive movements

27. THANK YOU