The initial stages are clear:
1. Undue movement at the fracture site should he prevented by the use of temporary splintage until radiographic and any other examination is complete. This will reduce pain and haemorrhage and minimise the chances of a closed fracture becoming open. In the case of the lower limb, support with pillows and sandbags may be adequate. In both the upper and the lower limbs inflatable splints arc invaluable.
2. If the deformity is so great that the fracture or dislocation is seriously endangering the viability of the overlying skin, it is usually advisable to do something to correct this: in many cases gentle repositioning of the distal part of the limb is sufficient; the use of Entonox may be required.
3. If the fracture is an open one, a bacteriological swab should be taken and the wound covered with sterile dressings. Finn bandaging may be required if brisk bleeding is continuing. If a polaroid photograph is taken of the wound prior to covering il. this will eliminate the need for the removal of dressings for repeated inspection by other members of staff. Antibiotic-therapy should be commenced immediately: the choice of therapy is dependent on the current status of bacterial flora in wound infections occurring in the particular local situation.
4. The fracture should be fully assessed by clinical and radiological examination: the site, pattern, displacement and angulation should be noted. Involvement of the skin, and damage to related structures such as important nerves or blood vessels should be assessed.
With this information the following key decisions must be made:
• Does the fracture require reduction?
• If reduction is required, how is it planned to carry this out?
• What support is required till union occurs?
• If the fracture is open, how will this influence treatment?
• Does the patient require admission to hospital, and what rehabilitation will be required?
• II reduction is required, Aplcy's summary of 'reduce, maintain, rehabilitate' is apposite.
Some observations about these decisions will be made in sequence.
Does the fracture require reduction? It is obvious that an undisplaced fracture does not require reduction, but unfortunately one still sees fractures in anatomical position subjected to manipulation, although only rarely are they displaced as a result of this.
If a fracture is only slightly displaced, reduction may nevertheless be highly desirable, as for example in fractures involving the ankle joint, where even slight persisting deformity may lead to the development of osteoarthritis. In other situations, some displacement may often be accepted, depending on:
1. the site involved,
2. where good remodelling may be anticipated (especially in children)
3. if ihe patient is very old, when the risks of anaesthesia, etc. may be considered to outweigh a problematical improvement.
If the fracture is appreciably angled or rotated, reduction is generally essential for cosmetic and functional reasons (but see under appropriate fractures).
If the fracture requires reduction, how is it planned to carry this out?
1. The commonest method is by the application of traction, followed by manipulation of the fracture, under general anaesthesia. General anaesthesia has most to offer in terms of muscle relaxation, duration and overall versatility, but for minor procedures regional anaesthesia and intravenous diazepam are popular and useful measures, with the advantage that waiting lime may be reduced.
2. Continuous traction is used to achieve a reduction in fractures of the femur and fracture dislocations of the cervical spine. It is used less commonly for a number of other fractures.
3. Open reduction of the fracture is carried out:
(i) as an obvious part of the treatment of an open fracture, i.e. debridement of the wound exposes the fracture which may be reduced under vision
(ii) where conservative methods have failed to give a satisfactory reduction
(iii) where it is considered that the best method of supporting the fracture involves internal fixation, and exposure of the fracture is a necessary part of that procedure.
What support is required until union of the fracture occurs?
Non-rigid methods of support Arm slings, bandages and adhesive strapping may be used, and serve some of the following purposes.
1. Firm support, e.g. in the form of crepe bandaging or circular woven bandaging, may help to limit swelling and oedema, and restrict the spread of haematoma.
2. Slings are often employed for elevation purposes, especially to limit gravitational swelling of the hand and lingers in upper limb injuries.
3. Pain may be relieved by the restriction of movement.
4. By restriction of limb movement, forces acting on the bone ends may be reduced to a level at which relative movement is unlikely, or insufficient to interfere with healing. This applies particularly to impacted fractures.
Continuous traction Traction may be maintained for several weeks, while holding a fracture in reduction. Fractures of the femoral shaft are frequently treated by this method. Traction may be effected through the skin (skin traction) by. for example, adhesive strapping, or through bone (skeletal traction) by, e.g.. a Steinman pin.
Plaster fixation Plaster of Paris, generally in the form of plaster-impregnated bandages, is the commonest method of supporting a fracture. The plaster is carefully moulded to fit the contours of the limb, and the quick-setting properties of the plaster allow the limb to be held without undue strain in the correct position until setting has occurred. For a plaster to achieve its purpose, care must be taken over its application and subsequent supervision. A disadvantage of plaster splints is that they soften if they are allowed to become wet. There are a number of plaster substitutes now available to overcome this problem, but none as yet combine the unique properties of plaster with moderate cost.
Internal fixation Internal fixation is indicated:
1. Where a fracture cannot be reduced by closed methods (e.g. a fracture of the tibia with soft tissue between the bone ends, or many fractures of the forearm bones).
2. Where a reduction can be achieved but it cannot be satisfactorily held by closed methods (e.g. fractures of the femoral neck, certain fractures of the tibial and humeral shaft).
3. Where a higher quality of reduction and fixation is required than can be obtained by closed methods (e.g. some fractures involving articular surfaces).
4. In the case of multiple injuries involving the lower extremities, where the risks of acute respiratory distress syndrome (ARDS). fat embolism and other serious post-injury complications are considerably reduced by early operative stabilisation of lower extremity (especially femoral) fractures. (Respiratory function is improved when the patient can sit up. reducing abdominal pressure on the diaphragm with its risks of atelectasis: and less analgesia is required for fracture pain, with less respiratory depression resulting.)
The present tendency in dealing with patients with multiple injuries is to stabilise (with internal or external fixation) all major lower limb fractures as soon as the patient's general condition will allow, and preferably as part of the initial treatment on the day the injuries are sustained.
In addition, there is a controversial area where the risks of internal fixation in a particular set of circumstances are outweighed, in the experience and opinion of the surgeon in charge, by the advantages. Some of the factors involved may include:
1. The possibility of achieving and maintaining a high quality reduction.
2. Earlier mobilisation of joints, with less risk of permanent stiffness, disuse osteoporosis, etc.
3. Earlier discharge from hospital, and earlier return to full function (including work, athletic activities, etc.).
Some of the disadvantages of internal fixation are:
1. The possibility of introducing infection. The consequences may be serious (e.g. chronic bone infection with non-union, which may sometimes necessitate amputation).
2. Internal fixation techniques require a degree of mechanical aptitude and experience on the part of the surgeon if the occasional serious failure is to be avoided.
3. To cover a wide range of fracture situations, a fairly formidable number of instruments and fixation devices will be required.
4. As on the whole the time under anaesthesia is much longer than when conservative measures are employed, the patient's general condition and health is of greater concern: the services of an expert anaesthetist arc more frequently required.
The methods of achieving internal fixation include the use of a wide range of devices (screws, nails, plates, etc.).
External skeletal fixation With this method, the bone fragments are held in alignment with pins inserted percutaneously. Two common methods of placing the pins are used: in one. each pin is passed through the skin and a bone fragment, and exits through the skin on the other side. More commonly, a cantilever system is used, with rigid pins which are screwed into a bone fragment and protrude from one side of the limb only. One to six pins are fixed in each bone fragment. The fracture is reduced with the pins in situ (at open operation, or by using an image intensitier). The pins are then held in proper relation to one another by a rigid external support. The ends of the pins are normally connected together with clamps; in emergency situations plaster bandages may be used for this purpose.
Such systems are of particular value in the management of open fractures where the stale of the skin and other factors may make the use of internal fixation devices undesirable. Cantilever (one-sided) systems give the best access for the dressing of open wounds.
In the Ilizarov method of external fixation, control of the major fragments of the shaft of a bone is obtained by fine wires passed through skin and bone, and held under tension on metal toroidal frames encircling the limb. Two or more frames are used for each major fragment, and these are held in alignment by threaded spacers.
Hybrid systems (such as the Sheffield system) are of particular value in treating fractures of the ends of long bones involving the related joints. Wires under tension are held in an Ilizarov type frame which is linked to pins inserted in the shaft.
The use of external fixators is sometimes followed, even in the case of closed fractures, by pin track infections. The quality of the fixation is also dependent on the pins remaining tight in the bone, and there is some risk of non-union.
Cast bracing Cast bracing techniques are sometimes employed some weeks after the initial conservative management of a fracture. The method is used particularly in the treatment of fractures of the femur and tibia. In the case of fractures of the femur, one method employs two supports - one for the thigh and one for the leg below the knee - linked together by hinges at the side of the knee. Sufficient fixation may be achieved thereby to allow early ambulation.
Plastic splints A number of off-the-shelf plastic splints are available for the immediate or delayed support of certain fractures (e.g. of the humeral shaft), and have hygienic advantages. Some incorporate hinges.
If the fracture is open, how will this influence treatment?
The following points will require separate consideration:
1. As debridement of the wound will almost certainly be needed, general anaesthesia and theatre facilities are essential. Pulsatile lavage may be used to reduce the amount of bacterial contamination, bearing in mind the adage 'the solution to pollution is dilution'.
2. In every case, potential difficulty in skin closure and cover of the fracture must be anticipated, and at least one possible line of treatment worked out prior to the patient being taken to theatre.
3. If the wound is badly soiled, and the skin damage substantial, the use of large implants is discouraged. The wider stripping of the tissues required for the insertion of some internal fixation devices may disseminate any infecting organisms and cause further (albeit local) tissue damage. The presence of inert material in the tissues may act as a nidus for infection, so that it is difficult for any local infection to be overcome. The bulk of an internal fixation device may make wound closure more difficult, and subsequent swelling is more likely to lead to sloughing of devitalised skin over any prosthesis. If intramedullary nailing is to be employed, reaming of the medullary canal should be avoided.
If wound contamination is judged to he slight, and if good cover of the fracture can he obtained, internal fixation of the fracture is often carried out where it is felt to contribute to the chances of union and a successful outcome. Where there is much tissue damage, and the risks of infection are high, the use of an external fixator should be considered.
4. Open fractures are usually associated with greater damage to surrounding soft tissues than closed fractures. Postoperative swelling is invariable, is often severe, and may lead to circulatory impairment in the limb. Special precautions must be taken over the type of splintage used, and the limb must be elevated. Admission for observation of the patient and of the limb circulation is almost invariably required.
In some cases there is serious elevation of pressure within the closed fascial compartments of the limb giving rise to one or several recognised compartment syndromes: these may be suspected on clinical grounds, and be confirmed by manometry. (In performing this an electronic transducer-tipped catheter gives the most accurate results.) In those situations where the clinical findings are difficult to assess (e.g. in the unconscious patient or in the presence of multiple injuries), and where particular compartments are at risk, continuous prophylactic monitoring may have to be considered. In weighing up the findings, the diastolic blood pressure should be taken into account. A differential pressure (diastolic blood pressure minus the intracompartmental pressure) of 30 mmHg or less is regarded as an indication for surgical decompression (by fasciotomy). (See also p. 99.)
5. As a rule, open fractures arc associated with greater violence, more initial deformity and more direct soft tissue damage. Neurological and vascular damage is more common, and should be looked for: if found, then the appropriate additional treatment will be required.
6. The majority of open fractures have microbial contamination which may be of both gram negative and gram positive organisms. The risk of the development of infection is closely related to the degree of soft tissue injury. There are special risks from organisms acquired from farmyards, fresh water contamination, and hospital environments (e.g. Clostridium perfringens. Pseudonwtias aeruginosa, penicillin-resistant staphylococci). It is considered that the duration of antibiotic courses should be short to reduce the risks of the emergence of resistant strains. Swabs should be taken from wounds on admission.
Gustilo el al recommend the following:
• Type I fractures: a single dose of 2.0 g of cephalosporin on admission followed by 1.0 g every 6-8 h for 48-72 h
• Type II or Type III injuries: gram negative and gram positive prophylaxis is necessary, as well as cephalosporin in the previously recommended dosage. The patient should be given aminoglycosides (tobramycin). 1.5 mg per kg body weight on admission, and 3.0-5.0 mg per kg body weight daily thereafter in divided doses. This must be adjusted if there is renal insufficiency. If there is risk of clostridial infection. 10 million units of penicillin should also be given. If any secondary procedure (e.g. internal fixation, delayed wound closure) is being performed, the antibiotic courses should be repeated.
Attention should also be paid to tetanus prophylaxis. If wound contamination is judged to be slight, antibiotics may or may not be given, depending to some extent on the assessment of the particular
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