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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 
  • 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)

 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.

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.

Complications

  • 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
  • Late (months-years): malunion, non-union, delayed union, osteoarthritis, avascular necrosis

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.

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

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/hemiarthroplastyUndisplaced/displaced <60 years → cannulated screws
Neck of femur (extracapsular)Intertrochanteric → dynamic hip screw/gamma nailSubtrochanteric → 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
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