FRACTURES-MANAGEMENT

[Drsumitra]

Before definitive treatment of a fracture is undertaken, attention must be
directed to first aid treatment (Advanced Trauma Life Support (ATLS)
principles), to the clinical assessment of the patient with special reference to the
possibility of associated injuries or complications, and to resuscitation.
Haemorrhage hardly ever demands a tourniquet for its control. All ordinary
bleeding can be controlled adequately by firm bandaging over a pad. Only if
profuse pulsatile (arterial) bleeding persists despite firm pressure over the
wound, with the patient recumbent, does the need for a tourniquet arise.
Pending its application, firm manual pressure over the main artery at the root
of the limb may be applied to control the bleeding. If a tourniquet is applied,
those attending the patient should be made aware of the fact and of the time of
its application. If necessary, a note to this effect should be sent with the patient
to ensure that the tourniquet is not inadvertently left in place for too long.If morphine or a similar drug is given at the scene of the accident a note to
that effect should be sent with the patient on admission to hospital.
Clinical assessment
It must be emphasised again that an immediate assessment of the whole
patient is required to exclude injuries to other systems before examination of
the skeletal injury. Examination of the limb should determine:
1. whether there is a wound communicating with the fracture
2. whether there is evidence of a vascular injury
3. whether there is evidence of a nerve injury
4. whether there is evidence of visceral injury.

        

[Drsumitra]

REDUCTION
This first principle must be qualified by the words ‘if necessary’. In many fractures
reduction is unnecessary, either because there is no displacement or
because the displacement is immaterial to the final result (Fig. 3.1). A considerable
experience of fractures is needed before one can say with confidence
whether or not reduction is advisable in a given case. If it is judged that perfect
function can be restored without undue loss of time, despite some uncorrected
displacement of the fragments, there is clearly no object in striving for perfect
anatomical reduction. Indeed, meddlesome intervention may sometimes be
detrimental, especially if it entails open operation.
To take a simple example, there is no object in striving to replace perfectly
the broken fragments of a child’s clavicle, because normal function and
appearance will be restored without any intervention
METHODS OF REDUCTION
When reduction is decided upon it may be carried out in three ways:
1. by closed manipulation
2. by mechanical traction with or without manipulation
3. by open operation.

FIXATION
The basic goal of fracture fixation is to stabilize the fractured bone, to
enable fast healing of the injured bone, and to return early mobility and
full function of the injured extremity. Fractures can be treated conservatively
or with external and internal fixation. Conservative fracture
treatment consists of closed reduction to restore the bone alignment.
Subsequent stabilization is then achieved with traction or external
splinting by slings, splints, or casts. Braces are used to limit range of
motion of a joint. External fixators provide fracture fixation based on
the principle of splinting. There are three basic types of external fixators:
standard uniplanar fixator, ring fixator, and hybrid fixator. The
numerous devices used for internal fixation are roughly divided into a
few major categories: wires, pins and screws, plates, and intramedullary
nails or rods. Staples and clamps are also used occasionally for osteotomy
or fracture fixation. Autogenous bone grafts, allografts, and
bone graft substitutes are frequently used for the treatment of bone
defects of various causes. For infected fractures as well as for treatment
of bone infections, antibiotic beads are frequently used.

IMMOBILISATION
Like reduction, this second great principle of fracture treatment must be
qualified by the words ‘if necessary’. Whereas some fractures must be splinted
rigidly, many do not require immobilisation to ensure union, and excessive
immobilisation is actually harmful in some (Figs 3.2 & 3.3).
INDICATIONS FOR IMMOBILISATION
There are only three reasons for immobilising a fracture:
1. to prevent displacement or angulation of the fragments
2. to prevent movement that might interfere with union
3. to relieve pain.
METHODS OF IMMOBILISATION
When immobilisation is deemed necessary there are four methods by which it
may be effected:
1. by a plaster of Paris cast or other external splint
2. by continuous traction
3. by external fixation
4. by internal fixation.

        

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