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Fracture management

Include in assessment

  • Who – age, job, hobbies, hand dominance (if hand/arm involved)
  • What happened, exact mechanism, force
  • When/where/why it happened (was it the result of another problem, e.g. collapse?)
  • Examine for other injuries
  • Check neurovascular status distally
  • Look for complications, e.g. compartment syndrome
  • Include social history and smoking (delays bone healing)

Fracture management stages include (4 R’s):

  1. Resuscitate
  2. Reduce (if displaced) – may be done by open reduction, closed manipulation or traction
  3. Retain (to maintain position while healing occurs) – by internal fixation, external fixation or conservative methods
  4. Rehabilitate

REsuscitate

  • Advanced trauma life support in life-threatening wounds (see ATLS)
  • Look for other injuries (don’t get distracted by one obvious injury!) – does the cervical spine need to be immobilised?

REduce

(if displaced)

  • Open reduction – when anatomical (perfect) reduction is required (e.g. for intra-articular fractures) or associated neurovascular damage
  • Closed manipulation (may be done in emergency department or require general anaesthesia) for extra-articular fractures where adequate and acceptable reduction can be achieved
  • Traction (to aid reduction, analgesia and in patients who are unsuitable for anaesthesia)

Learn more here…

Learn about closed fracture manipulation here!

REtain

(to maintain reduced position while callus forms in ~ 6 weeks)

  • External fixation – required for: contaminated open wounds, severe open fractures, severe associated soft tissue injury
  • Internal fixation – required for: comminuted or displaced fractures, intra-articular fractures, bones not able to be reduced by other methods, associated joint incongruity
    • Intramedullary
      • Intramedullary nail – for long bone fractures (femur/tibia/humerus)
      • K-wires (stainless steel pins which can be inserted percutaneously to hold bone fragments together; can be used as temporary fixation for ~4 weeks) – for fracture fragments or for intramedullary fixation of small bones  
    • Extramedullary
      • Plates and screws – to bridge comminuted fractures, compress simple fractures around joints, support areas of thin cortex or secure tension side of fracture
  • Conservative immobilisation – can be used for most fractures without above properties, and also to stabilise fractures temporarily in case of delay before reduction/fixation
    • Splints and casts
      • Splint (non-circumferential immobiliser), e.g. plaster backslab, fibreglass backslab, aluminium/wire/heat-mouldable plastic splints 
      • Cast (circumferential immobiliser), e.g. fibreglass cast, full plaster cast 
    • Brace (supportive device that allows continued function)
    • Sustained traction:
      • Collar and cuff arm sling
      • Skin traction (adhesive strappings around parts of limb distil and proximal to fracture, and weight traction applied to each in opposite directions)
      • Traction splint 
      • Skeletal traction (pins passed through bone to provide point of traction)

NB: femur and tibia/fibula shaft fractures can be managed conservatively but are usually managed with intramedullary nailing to reduce time non-weight-bearing.

Learn more here…

Learn how to apply a backslab and cast here! Slings, splints and braces are also covered here.

REhabilitate

  • Physiotherapy to regain function
  • Consider weight-bearing status of affected lower limb
    • imageNon-weight-bearing (leg must not touch floor) – for ~6 weeks in conservatively managed unstable fractures and after fixation with plates 

Other aspects to management

  • For swelling, RIE: Rest, Ice, Elevation
  • Smoking cessation – delays bone healing 
  • Analgesia (but avoid NSAIDs – they interfere with bone healing)
  • Antibiotic prophylaxis for open fractures 
  • VTE prophylaxis
  • Treat the cause of the fracture if necessary, e.g. osteoporosis, fall etc.

Other points

  • Timings
    • Callus forms in 6 weeks – temporary fixations (e.g. traction, cast, external fixations, K-wires) removed at this stage
    • Full fracture healing in 12 weeks
    • Generally, lower limb bones take twice as long to fully heal as upper limb bones, and young children’s bones heal twice as fast as adult’s bones
  • Repeat X-rays are performed post-operatively or after cast application 
  • Fractures with a fragment at risk of avascular necrosis due to retrograde blood supply: 
    • Head of femur 
    • Waist of scaphoid
    • Neck of talus

Specific management of common fractures

ClavicleBroad arm sling or polysling 
Proximal humerusCollar and cuff sling (applies traction)
Mid-humerusCollar and cuff sling + U-slab cast, or functional brace
Distal humerusAbove elbow backslab/cast
Colles’ fractureClosed manipulation under haematoma block then Colles’ backslab/cast (below elbow backslab/cast with wrist flexed and ulnar deviated) applied
ScaphoidFuturo splint ± thumb extension, or thumb spica splint/cast if definite fracture
Neck of femur (intracapsular)Displaced >60 years → total hip replacement/hemiarthroplasty
Undisplaced/displaced <60 years → cannulated screws
Neck of femur (extracapsular)Intertrochanteric → dynamic hip screw/gamma nail
Subtrochanteric → intramedullary nail
Femur/tibia shaftIntramedullary nail
Lateral malleolus (Weber A)Below knee backslab/cast or aircast boot or stirrup brace (full weight-bearing)
Bimalleolar, trimalleolar or lateral malleolar fractures that disrupt the syndesmosis (i.e. Weber C and some Weber B)Surgical fixation

Test yourself, what are the complications of fractures?

Immediate

  • Haemorrhage
  • Arterial damage
  • Surrounding structure damage (e.g. tendons, nerves)
  • Fat embolus

Early (few weeks)

  • Wound/prosthesis infection
  • Loss of position/fixation
  • VTE
  • Chest infection
  • Compartment syndrome

NB: compartment syndrome is a rise in pressure in a myofascial compartment. It causes pain out of proportion to the injury and is exacerbated by passive stretching of the muscles within the compartment. The treatment is urgent fasciotomy.

Late (few months)

  • Malunion
  • Non-union
  • Delayed union
  • Osteoarthritis
  • Avascular necrosis
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