Basics of Fracture Management

Question 1

What are some of the most important factors to determining fracture treatment?

Answer 1

• Stability of the fracture
• Patient fitness
• Open vs. Closed fracture

Question 2

How does fracture type correspond to fracture stability?

Answer 2

Transverse fracture = stable

Oblique, Spiral and Comminuted = unstable

Question 3

What is an open fracture?

Answer 3

A fracture in which there is direct communication between the external environment and the fracture

(skin completely penetrated)

Question 4

What is the Gustilo Grading?

Answer 4

Grading of open fractures according to energy of the impact causing damage & associated complications.

Graded 1-3 from lower to high energy wounds

Question 5

What are the steps to management of open fractures?

Answer 5

1. Tetanus and antibiotic prophylaxis
2. Photograph, cover and stabilize limb
3. Surgery - all surgery within 24 hours (wound excision / bone grafting etc.)

Question 6

What are the initial steps to fracture treatment?

Answer 6

• Immobilization
• Pain relief
• Clinical examination (fracture, circulation, neuro)
• Radiological examination
• Reduction of bones

Question 7

What are some options for conservative treatment of fractures? (assuming the bones are reduced already)

Answer 7

Support:
- Strapping / elastic bandage / brace

Immobilization:

• Cast
• Functional Brace
• Traction

Question 8

What are the three principles of fracture casts?

Answer 8

• Three point loading (apply pressure at the distal ends of the fractured bones, and then at the spot of the fracture from the opposite side - straightens)
• Hydraulics (stop the soft tissue from bulging at the sides prevents shortening)
• Rotational control

Question 9

What is the soft tissue hinge?

Answer 9

The soft tissue that articulates with the fracture segments on the concave side of the fracture prevents over-reduction, acts as a spring

(Bending the fracture more can start reduction of the bones)

Question 10

What are the main goals of functional bracing?

Answer 10

Prevent angulation / rotation of the bone.

• Usually applied once the bone has become “sticky” and will no longer shorten
• Allows for partial / full movement of joints to avoid them becoming stiff with prolonged immobilization

Question 11

What is traction in regards to fracture management?

Answer 11

Providing axial (along the length of the bone) force to the fracture allows the bones to realign if they have been displaced

Reduces the two bones, once the bones have become “sticky” can remove traction apparatus and apply functional brace

Question 12

What are some methods of applying traction to fractures?

Answer 12

Skin traction - adhesive or non-adhesive tape attaches to skin, put weight on other end of the pulley and this provides traction to fracture (Mostly young children / less severe breaks)

Bone traction - pin passed through bone to provide traction instead of tape, allows for heavier loading

Question 13

What are the two main methods of fixating bones operatively?

Answer 13

External fixation - pins / screws / plates placed around the fracture outside of the body. Used when there is lots of soft tissue damage, in limb reconstruction

Internal fixation - incision over the fracture so it’s exposed, allows for bone grafting and earlier joint mobilization

Question 14

What are the different types of external fixation setups?

Answer 14

Unilateral frame - strut running down one side of the limb

Multilateral frame - struts on multiple sides of the limb

Circular frame - wraps completely around the limb w pins inserting into the limb

Question 15

What are some of the possible complications associated with fracture treatment?

Answer 15

• Neurovascular injury
• Pin tract infection
• Loss of fracture alignment
• Joint contractures (stiffening)
• Slow union of bones

Question 16

When is intramedullary nailing indicated as treatment? What is it?

Answer 16

Indicated in long bone diaphyseal fractures:

• Tibial / femoral / humeral
• Paediatric fractures

It is passing a nail through the medulla of a bone to splint and assist in proper healing

Question 17

Describe the procedure of inserting a intramedullary nail

Answer 17

• Patient positioned and fracture reduced
• Small incision made and X-Ray guided entry of wire
• Medullary canal reamed (drilled - think oil well)
• Pass nail into cavity
• Lock bone onto nail via screws at proximal and distal end

Question 18

What are some of the advantages of intramedullary nailing?

Answer 18

• Incisions are remote from the fracture (less chance of direct infection)
• Minimal fracture exposure (preserves periosteum as well as soft tissue)
• Joints are free to move

Question 19

What are some of the risks for internally fixating fractures?

Answer 19

• Devascularization due to tissue damage from operation
• Wound problems due to proximity of incision to fracture
• Infection

Question 20

How can screws be used to improve fracture healing?

Answer 20

1. Fix the pieces of bone together
2. Compress the fracture: hole is bigger on one of the bones so the screw is only fixed to one of the fragments, pulls this one towards the other and compresses the fracture

Question 21

How are plates used to improve fracture healing?

Answer 21

Load sharing - plate fixed to the bone via screws, initially the plate takes more weight but eventually the bone takes over

Plate will eventually fail due to overuse, need the bone to heal before this

Question 22

What are the different types of plates that can be used to repair fractures?

Answer 22

Compression - squeeze fragments together

Neutralization - resist rotational forces

Buttress - stops collapse of fragments

Bridging / Strut - don’t open the fracture. Incision made at distal end of joint and plate slid in