EARLY MANAGEMENT OF

FRACTURE TREATMENT
Cause

• Trauma. A fall, a motor vehicle accident, or a tackle during a

football game can all result in fractures.
• Osteoporosis. This disorder weakens bones and makes them
more likely to break.
• Overuse. Repetitive motion can tire muscles and place more
force on bone. This can result in stress fractures. Stress fractures
are more common in athletes.
Common type of fractures

Varieties of fracture Complete fractures: (a) transverse; (b) segmental and (c)
spiral. Incomplete fractures: (d) buckle or torus and (e,f) greenstick.
CLINICAL FEATURES
• History of injury, followed by
inability to use the injured limb
• Pain, bruising and swelling
• Deformity (angulation, rotation,
shortening, translation)
 General signs –
PRIMARY SURVEY FRACTURE

Airway obstruction

Breathing problems

Circulatory problems HEMORRHAGE FROM LONG BONE

FRACTURES MAY BE SIGNIFICANT 
FEMORAL FRACTURES RESULT IN
SIGNIFICANT BLOOD LOSS INTO THE
THIGH
ADJUNCTS TO PRIMARY SURVEY – FRACTURE
IMMOBILIZATION
GOAL:
• Realign injured extremity in as close to anatomic position as possible
• Prevent excessive fracture-site motion.

IN LINE TRACTION with immobilization device

Proper application of splint

• Help control blood loss
• Reduce pain
• Prevent further soft tissue injury
SECONDARY SURVEY – HISTORY TAKING

•Mechanism of injury
Key •Preinjury status
•Predisposing factors
aspect •Prehospital observations and
care
SECONDARY SURVEY – PHYSICAL EXAMINATION

THREE Goals for assessment of trauma patient’s extremities

• Identification of life-threatening injuries (PRIMARY

SURVEY)
• Identification of limb-threatening injuries (SECONDARY
SURVEY)
• Systematic review to avoid missing any other musculoskeletal
injury (CONTINUOUS REEVALUATION)
Potential life-threatening injuries

Unstable pelvic fractures

Major arterial hemorrhage

Crush syndrome
(traumatic rhabdomyolysis)
UNSTABLE PELVIC FRACTURES
• Initial survival depend on prevention
of death from hemorrhage
adequate replacement for blood
lost, and control ongoing bleeding
• Disruption of the posterior osseus-
ligamentous (sacroiliac, sacrospinous,
sacrotuberous)
• Unstable injury characterized by the
type of displacement as:
• Rotationally unstable
• Vertically unstable
 Presentation
• ABCs (airway, breathing, circulation)
• MOI.
• Destot sign, superficial hematoma above
the inguinal ligament, in the scrotum, or in
the thigh
• Look for a rotational deformity of the
pelvis or lower extremities.
• LLD may also present with pelvic
fractures.
• Lower extremities must undergo a
thorough neurovascular examination
• Unexplained hypotension may be the only indication of
major pelvic disruption
• Physical signs: progressive flank, scrotal, perianal swelling
and bruising
• Mechanical instability, is test by manual manipulation
(should be performed only once!)
• Sign of instability:
• leg length discrepancy or rotational deformity usually external
• Open wound in flank, perinium, rectum
Imaging
Plain radiography
• Unstable fractures characterized by
• Hemipelvic cephalad
displacement that exceeds 0.5
cm SI diastasis that exceeds 0.5
cm.
• Findings suggestive of pelvic
instability include cephalad
hemipelvic displacement less
than 1 cm and/or a diastatic
fracture of the sacrum or ilium
less than 0.5 cm.
• All trauma patients in whom the spine cannot be clinically
cleared must receive full cervicothoracolumbosacral (CTLS)
spine series.
• Initial evaluation  chest radiography.
Evaluate pathology includes pneumothorax, pulmonary
contusion, and acute respiratory distress syndrome (ARDS).
Management
• Hemorrhage control
and rapid fluid
resuscitation
• Pelvic C-clamp
• Longitudinal skin or
skeletal traction
• Pelvic sling
• PASG
• Open pelvic
fracturepacking the
open wound
Pelvic wrap
MAJOR ARTERIAL HEMORRHAGE

• Penetrating extremity wounds

Caused by • Blunt trauma

• External bleeding
• Loss a previously palpable pulse

Assessment •
•
Change in pulse equality
Doppler tone
• Ankle/brachial index
• Rapidly expanding hematoma
Management
• Application of direct pressures to the open
wound
• Aggressive fluid resuscitation
• Pneumatic torniquet
• Vascular clamp is not recommended unless
superficial vessel is clearly identified
• If a fracture is associated with an open
hemorrhaging wound, fracture should be
realignment and splinting
• Consultation with surgeon skilled in vascular
and extremity trauma
 CRUSH INJURY
&
CRUSH SYNDROME
• Crush injurycompression of
extremities and body parts that
causes muscle swelling and/or
neurological disturbances in the
affected parts of the body

• Crush syndromelocalized crush

injury with systemic
manifestations. Systemic effects
caused by a traumatic
rhabdomyolysis and the release of
toxic muscle cell components and
electrolytes into the circulation
Synonym : Bywaters’ Syndrome
Management of crush
injuries • Apply pressure dressing to gross arterial bleeding
• Don’t attempt blind clamping of bleeding vessels.
• Correct gross misalignment of extremities by
gentle application and repositioning of extremity
to better approximate normal anatomy.
• Flood open wounds with sterile saline solution
and cover with antiseptic soaked gauze dreesings.
• Apply splinting material to immobilize the injured
extremity
• Apply adequate antibiotic and antitetanus
 Diagnosis criterias of crush
syndrome
1. Crushing injury to a large
mass of skeletal muscle
2. The sensory and motor
disturbances, tense and
swollen
3. Myoglobinuria and/or
hematuria
4. Peak creatine kinase (CK) >
1000 U/L
Management of crush syndrome
• ABC
• Hypotension  fluid replacement
• Renal failure
• Prevent renal failure through appropriate hydration
• Maintain diuresis 300cc/hr with IV fluids and mannitol 20%
• Metabolic abnormalities
• IV Sodium bicarbonate 50-100 meq/l until urine pH reach 6,5
• Hyperkalemia/Hypocalcemiaadminister calcium, sodium bicarbonate, insulin/D5%
• Cardiac arrhytmiasclose monitoring
• Amputation
• Fasciotomy: controversial
• Hyperbaric oxygen therapy
Limb-threatening injuries

Open Compartment
Dislocation
fractures syndrome
 • Osseous disruption in which a break in
the skin and underlying soft tissue
OPEN FRACTURES communicates directly with the fracture
and its hematoma

• Soft tissue injuries :

• Contamination of the wound and
fracture
• Crushing, stripping, and
devascularization soft tissue
• Destruction or loss of the soft tissue
envelope
Complete assessment of the open fracture
• reviewing the mechanism of injury,
• condition of the soft tissues,
• degree of bacterial contamination,
• characteristics of the fracture

Help to classify the fracture,

determine the treatment regimen,
and establish the prognosis and
potential clinical outcome
CLINICAL EVALUATION
• ABCDE
• Initiate resuscitation and address
life-threatening injuries.
• Evaluate injuries to the head,
chest, abdomen, pelvis, and spine.
• Identify all injuries to the
extremities.
• Assess the neurovascular status of
injured limb(s).
• Assess skin and soft tissue
damage
• Obtain necessary radiographs
 Type~I of Open Fracture of the Lower Leg

I <1 cm Clean Minimal Simple, minimal

long comminution
 Type~II Open Fracture of the Lower Leg

II >1cm Moderate Moderate, some muscle damage Moderate

long comminution
Type~II Open Fracture of the forearm

II >1cm Moderate Moderate, some muscle damage Moderate

long comminution
 Type~III Open Fracture of the Fore Arm

III
A Usually High Severe with crushing Usually comminuted;
>10 cm soft tissue coverage of
long bone possible
B Usually High Very severe loss of coverage; Bone coverage poor;
>10 cm usually requires soft tissue variable, may be
long reconstructive surgery moderate to severe
comminution
 Type~IIIC Open Fracture of Femur

IIIC Usually High Very severe loss of coverage Bone coverage poor;
>10 cm plus vascular injury requiring variable, may be
long repair; may require soft tissue moderate to severe
reconstructive surgery comminution
 EMERGENCY ROOM MANAGEMENT

1. Careful clinical and radiographic

evaluation.
2. Wound hemorrhage  direct pressure!
rather than limb tourniquets
3. Initiate parenteral antibiotic(see later).
4. Assess skin and soft tissue damage;
place a saline-soaked sterile dressing on
the wound.
5. Perform provisional reduction of
fracture and place a splint.
6. Operative intervention
 Antibiotic coverage for open fractures

• Grade I, II : first-generation cephalosporin (Cefacetrile, cephalexin,

cephalotin, cephaloridine, cephapirin, cefatrizine, cefazedone, cefazolin,
cephradine, cefroxadine, ceftezole)
• Grade III: add an aminoglycosides
 • Do not irrigate, debride, or probe the
Important!! wound in the ER if immediate
operative intervention is
plannedmay further contaminate
the tissues and force debris deeper
into the wound.
• If a surgical delay is anticipated,
performed gentle irrigation with
normal saline.
• Bone fragments should not be
removed in the emergency room, no
matter how seemingly nonviable they
may be.
Fracture stabilization
(internal or external fixation)
• provides protection from
additional soft tissue injury,
• maximum access for wound
management,
• maximum limb and patient
mobilization
Soft tissue coverage and bone grafting
• Performed once there is no further
evidence of necrosis.
• Bone grafting can be performed when the
wound is clean, closed, and dry.
• The timing of bone grafting after free
flap coverage is controversial.
• Some advocate bone grafting at the time
of coverage; others wait until the flap has
healed (normally 6 weeks).
Limb salvage
In Gustilo Gr III, immediate or early
amputation indicated if:
• The limb is nonviable: irreparable
vascular injury, warm ischemia
time >8 hours, or severe crush with
minimal remaining viable tissue.
• After revascularization the limb
remains so severely damaged
• The patient presents with an injury
severity score (ISS; of >20)
DISLOCATION
Most commonly dislocated major joint
• Shoulder
• Elbow
• Hip
• Knee
Shoulder dislocation
• Anterior dislocation
• Posterior dislocation
• Inferior dislocation
Anterior Shoulder Dislocation
• 90% of shoulder dislocations
• MOI :
• indirect trauma shoulder in abduction, extension and external rotation
• direct: anteriorly directed impact to the posterior shoulder
• Patient presents with the injured shoulder held in slight abduction and external
rotation.
• Squaring of the shoulder
• Careful neurovascular examination is important (axillary nerve and
musculocutaneous nerve integrity)
Treatment of anterior shoulder dislocations

Closed reduction should be

performed after adequate clinical
evaluation and administration of
analgesics and/or sedation.
Described techniques include:
• Traction-countertraction
• Hippocratic technique
• Stimson technique
• Milch technique
• Kocher maneuver
Velpeau bandage
Complication
• Tear of rotator cuff
• Avulsion of greater tuberosity
• Brachial plexus or axillary nerve injury
• Instability  reccurrence (the most common
complication
ELBOW DISLOCATION
• Posterior dislocation is most common.
• Simple dislocations are those without
fracture.
• Complex dislocations are those that
occur with an associated fracture and
represent just under 50% of elbow
dislocations.
• Highest incidence in the 10- to 20-year
old age group associated with sports
injuries
MOI
• Most commonly, injury is
caused by a fall onto an
outstretched hand or elbow,
• Posterior dislocation: This is
a combination of elbow
hyperextension, valgus
stress, arm abduction, and
forearm supination
• Patients guard the injured
upper extremity
• A careful neurovascular
examination should be
performed before
radiography or manipulation.
• Following manipulation or
reduction, repeat
neurovascular examination
should be performed.
TREATMENT of Simple Elbow dislocation

Conservative
• For posterior dislocations, reduction should be performed with the elbow flexed
while providing distal traction.
• Neurovascular status should be reassessed, followed by evaluation of stable range
of elbow motion.
• Postreduction management should consist of a posterior splint at 90 degrees and
elevation.
• Early, gentle, active range of elbow motion is associated with better long-term
results
• Recovery of motion and strength may require 3 to 6 months.
Operative, indications:
• The elbow cannot be held in a
concentrically reduced position,
• Redislocates before postreduction
radiography,
• Dislocates later in spite of splint
immobilization,
• Dislocation is deemed unstable

three general approaches to this

problem:
(1) open reduction and repair of soft
tissues back to the distal humerus,
(2) hinged external fixation,
(3) cross-pinning of the joint.
HIP DISLOCATIONS
• Anterior dislocations
constitute 10% to 15%
of traumatic
dislocations of the hip,
with posterior
dislocations
accounting for the
remainder.
• Sciatic nerve injury is
present in 10% to 20%
of posterior
dislocations
MOI
• Almost always result from high-
energy trauma, such as motor
vehicle accident, fall from a
height, or industrial accident.
• Force transmission to the hip
joint occurs with application to
one of three common sources:
• The anterior surface of the
flexed knee striking an object
• The sole of the foot, with the
ipsilateral knee extended
• The greater trochanter
Anterior Dislocations

• Comprise 10% to 15% of

traumatic hip dislocations.
• Result from external rotation
and abduction of the hip.
Posterior Dislocations
• Much more frequent than
anterior hip dislocations.
• Result from trauma to the
flexed knee (e.g.,
dashboard injury) with the
hip in varying degrees of
flexion
 TREATMENT
Closed Reduction
Allis Method
• Patient supine with the surgeon standing
above the patient on the stretcher
• Surgeon applies in-line traction while
the assistant applies countertraction by
stabilizing the patients pelvis.
• Surgeon should slowly increase the
degree of flexion to approximately 70
degrees.
• Gentle rotational motions of the hip as
well as slight adduction
• A lateral force to the proximal thigh may
assist in reduction.
STIMSON GRAVITY TECHNIQUE
• Patient is placed prone on the
stretcher with the affected leg
hanging off the side of the stretcher.
• This brings the extremity into a
position of hip flexion and knee
flexion of 90 degrees each.
• In this position, the assistant
immobilizes the pelvis, and the
surgeon applies an anteriorly
directed force on the proximal calf.
• Gentle rotation of the limb may
assist in reduction
KNEE DISLOCATIONS
• High-energy: A motor vehicle
accident with a dashboard• injury
involves axial loading to a flexed
knee.
• Low-energy: This includes athletic
injuries and falls.
• Hyperextension with or without
varus/valgus leads to anterior
dislocation.
• Flexion plus posterior force leads to
posterior dislocation (dashboard
injury).
Dislocation of Knee

Classification
• Anterior dislocation: most common
• Posterior dislocation
• Superior dislocation
Clinical Evaluation
• Gross knee distortion
• Extent of ligamentous injury is related to
the degree of displacement, gross
instability may be realized after reduction
• Ligament examination is important
• A careful neurovascular examination is
critical, both before and after reduction
• Vascular injury : popliteal artery
disruption (20% to 60%)
• Neurologic injury : peroneal nerve (10%
to 35%). Commonly associated with
posterolateral dislocations
TREATMENT
• The posterolateral
dislocation is irreducible•
owing to buttonholing of
the medial femoral condyle
through the medial
capsuledimple sign over
the medial aspect of the
limb requires open
reduction
• The knee should be
splinted at 20 to 30 degrees
of flexion
Operative
• Indications :
• Unsuccessful closed reduction.
• Residual soft issue interposition.
• Open injuries.
• Vascular injuries.
• Vascular and ligamentous injuries should
be repaired.
ACUTE COMPARTMENT SYNDROME

Increased pressure within a closed fascial spaces of the arm, leg or other extremity,
most often due to injury, exceeds the perfusion pressure (enough to occlude
capillary blood flow) and results in muscle and nerve ischemia.
Etiologies of CS
• Decreased Compartment Size:
• Crush syndrome
• Closure of fascial defect
• Tight dressing or cast
• External pressure(PASG or direct pressure)
• Increased Compartment Content:
• Bleeding
• Edema
• Postischemic swelling
• Exercise
• Trauma
• Burn
• Intra arterial drug
• Orthopaedic surgery or trrauma
• Venous obstruction
Causes of compartment syndrome
 Energy is dissipated
Injury
into the muscle

Increased pressure,
intracellular
within the closed swelling
space

circulatory Ischemia and tissue

embarrassment damage
Clinical picture:
6~P
1. Pain
2. Pallor
3. Puffiness
4. Paresthesia
5. Paralysis
6. Pulselessness
The earliest, most consistent, and most reliable
sign is deep, unrelenting, vague but progressive
PAIN that is out of proportion to the injury and
not responsive to normal doses of pain
medication.
Surgical treatment
• Vascular repair and fasciotomy
Fasciotomy of the Lower Leg
GENERAL PRINCIPLES OF
FRACTURE TREATMENT
 • Swelling, bruising and deformity
• Does the skin intact ?
Look • Posture of the distal extremity
• Colour of the skin

• Injured part gently palpated for

localized tenderness.
Feel • Vascular and peripheral nerve
abnormalities should be tested for
both before and after treatment

• Crepitus and abnormal movement may be

present, but why inflict pain when x-rays
Move are available?
• Ask the patient to move the joints distal to
the injury
X-Ray – Rule of TWO

Two views Two joints

Two limbs Two injuries

Two occasions
 X-ray examination must be ‘adequate’
A B C D

G H

E
• (a,b) Two view
• (c,d) Two occasion
• (e,f) Two joints
• (g,h) Two limbs F
Special Imaging
• CT
• may be helpful in lesions of the spine or for complex joint
fractures
• for accurate visualization of fractures in ‘difficult’ sites :
calcaneum or acetabulum
• MRI is the only way of showing whether a fractured
vertebra is threatening to compress the spinal cord.
• Radioisotope scanning is helpful in diagnosing a
suspected stress fracture or other undisplaced
fractures.
Description a fracture
(1) Is it open or closed?
(2) Which bone is broken, and where?
(3) Has it involved a joint surface?
(4) What is the shape of the break?
(5) Is it stable or unstable?
(6) Is it a high-energy or a low-energy injury?
(7) Who is the person with the injury?
Treatment of closed fracture
• Manipulation
• Splintage
• Joint movement and function must be
preserved.
• Early weightbearing are encouraged.

Reduce
Three simple Hold
injunctions

Exercise
 Reduction
CLOSED
REDUCTION
OPEN
REDUCTION

• Used for all minimally

displaced fractures,
• For most fractures in
when there is a children
when closed
large articular
for traction • For fractures that are
fragment that
reduction (avulsion) stable after reduction
needs accurate
fails, fractures
positioning
How to hold reduction?

Showing how, if the soft tissues around a fracture are intact, traction will align the
bony fragments.
Methods of holding reduction :

Continuous
Cast splintage.
traction.

Functional
Internal fixation.
bracing.

External
fixation.
CONTINUOUS TRACTION
• cannot hold a fracture still
• patient can move the joints and exercise the
muscles.
• safe enough
• problem is speed: because lower limb traction
keeps the patient in hospital.
• Consequently, as soon as the fracture is ‘sticky’,
traction should be replaced by bracing
(a) Traction by gravity.
(b,c,d) Skin traction:
(b) fixed; (c) balanced;
(d) Russell.
(e) Skeletal traction with a
splint and a knee-flexion piece
CAST SPLINTAGE
• Safe enough
• The speed : patient go home sooner.
• Holding reduction is usually no problem and
patients with tibial fractures can bear weight on
the cast.
• Joints in plaster cannot move and are liable to
stiffen; stiffness ‘fracture disease’
(a) A well-equipped plaster trolley
is invaluable.
(b) Adequate anaesthesia and
careful study of the x-ray films are
both indispensable.
(c) For a below-knee plaster the
thigh is best supported on a
padded block.
(d) Stockinette is threaded
smoothly onto the leg.
(e) For a padded plaster the wool
is rolled on and it must be even.
(f) Plaster is next applied
smoothly, taking a tuck with each
turn, and
(g) smoothing each layer firmly
onto the one beneath.
(h)While still wet the cast is
moulded away from the point
points.
(i) With a recent injury the
plasteris then split.
FUNCTIONAL BRACING
• the fracture can be held reasonably well
• the joints can be moved;
• the fracture joins at normal speed without
keeping the patient in hospital
• the method is safe
 INTERNAL FIXATION, indication :
1. Fractures cannot reduced except by operation.
2. Unstable fractures and prone to re-displace after reduction
3. Fractures that unite poorly and slowly  fractures of the
femoral neck.
4. Pathological fractures
5. Multiple fractures
6. Fractures in patients who present nursing difficulties
(paraplegics, those with multiple injuries and the very elderly).
Types of internal fixation

Interfragmentary screws

Wires (transfixing, cerclage and tension-band)

Plate and screws

Intramedullary nails
(a) Screws
(b) Plate and screws
(c) Flexible intramedullary nails
(d) Interlocking nail and screws
(e) Dynamic compression screw
and plate
(f) Simple K-wires
(g) Tension-band wiring
Complications of internal fixation

Infection

Non Union

Implant failure

Refracture
Indications staircase
1. if the surgical skill or back-up
facilities are of a low order,
internal fixation is indicated only
when the alternative is
unacceptable
2. With average skill and facilities,
fixation is indicated when
alternative methods are possible
but very difficult or unwise
3. With highest levels of skill and
facilities, fixation is reasonable if
it saves time, money or beds.
External fixation, indication :
Fractures associated
with severe soft-tissue Ununited fractures
damage

Fractures around joints

that are potentially
suitable for internal Severe multiple injuries
fixation but the soft
tissues are too swollen

Infected fractures
Complications of external fixation

Damage to soft-tissue structures

Overdistraction

Pin-track infection
(a,b) temporary stabilization of
fractures in order to allow the
patient’s general condition or the
state of soft tissues to improve prior
to definitive surgery or
(c–f) reconstruction of limbs using
distraction osteogenesis.
(c) A bone defect after surgical
resection with gentamicin beads
used to fill the space temporarily.
(d) Bone transport from a more
proximal osteotomy.
(e) ‘Docking’ of the transported
segment and
(f) final union and restoration of
structural integrity.
EXERCISE
Swelling is minimized by improving
venous drainage.
(1) elevation
(2) firm support. Stiffness is
minimized by exercise.
(a,c) Intermittent venous plexus
pumps for use on the foot or palm
to help reduce swelling.
(b) A made-tomeasure pressure
garment that helps reduce swelling
and scarring after treatment.
(d) Coban wrap around a limb to
control swelling during treatment.
Prevention of oedema
• Important cause of joint stiffness,
especially in the hand
• The limb should be elevated and
active exercise begun as soon as the
patient will tolerate this.
• The essence of soft-tissue care may
be summed up thus: elevate and
exercise; never dangle, never force.
Elevation
• If the leg is in plaster, the limb 
be dependent for only short
periods and, the leg is elevated on
a chair.
• If the plaster is finally removed,
similar routine of activity
punctuated by elevation is
practised until circulatory control
is fully restored
Active Exercise
• Helps to pump away oedema fluid,
• Stimulates the circulation,
• Prevents soft tissue adhesion
• Promotes fracture healing
• A limb in plaster is still capable of static muscle
contraction and the patient should be taught
how to do this.
• When splintage is removed the joints are
mobilized and muscle-building exercises are
steadily increased.
• Remember that the unaffected joints need
exercising too
Assisted movement
• Forced movements should never be
permitted,
• Gentle assistance during active
exercises may help to retain
function or regain movement after
fractures involving the articular
surfaces.
• Done with machines that can be set
to provide a specified range and rate
of movement (‘continuous passive
motion’).
Functional activity
• be taught again how to perform everyday
tasks such as walking, getting in and out of
bed, bathing, dressing or handling eating
utensils
THANK YOU