Principles of Fracture Management

Question 1

Objective of fracture healing are covered by

three simple injunctions:

Answer 1

REDUCE=- Manipulation: Traction & 
force, usually reverse of 
mechanism of injury
- Mechanical Traction 
- Open Operation 

MAINTAIN (Immobilization)=1. Sustained traction
> Traction by gravity
> Balanced traction
> Fixed traction and

REHABILITATION (Exercise).=

• Prevent oedema
• Active exercise
• Assisted movement
• Functional activity

Question 2

types of Reduction=realign the fracture fragments:

Answer 2

Open operation- in Theatre

CLOSED:
- Manipulation: Traction & 
force, usually reverse of 
mechanism of injury
- Mechanical Traction 
- Open Operation

Question 3

PRINICPLE:MAINTAIN THE REDUCTION

1) TRACTION (closed reduction)?

Answer 3

Traction is applied distal to the fracture to exert a continuous pulling force along the shaft of a long bone. This is useful for fractures that have shortened due to unopposed muscle contraction. Usually maintained until union

Question 4

PRINCIPLE: MAINTAIN THE REDUCTION:

types of traction examples:

Answer 4

SKIN TRACTION= 
Max weight is 4-5 kg
 Usually temporary measure, except in children
 Cannot use adhesive tape over wounds
 Tape may cause skin irritation

SKELETAL TRACTION =
Traction applied through pins passed through bone
Strong loads can be applied

Question 5

MAINTAIN THE REDUCTION:
types of traction examples:
SKIN TRACTION

Answer 5

Max weight is 4-5 kg
Usually temporary measure, except in children
Cannot use adhesive tape over wounds
Tape may cause skin irritation

Question 6

MAINTAIN THE REDUCTION:
types of traction examples:
SKELETAL TRACTION

Answer 6

Traction applied through pins passed through bone

Strong loads can be applied

Question 7

MAINTAIN THE REDUCTION:

types of traction?

Answer 7

Traction may be fixed or dynamic.
Fixed traction can be achieved using a splint (eg Thomas splint) or
gravity (Gallows traction).

Various pulley systems used to apply dynamic traction

Question 8

MAINTAIN THE REDUCTION:

Fixed Traction

Answer 8

Fixed traction can be achieved using a splint (eg Thomas splint) or
gravity (Gallows traction).

Question 9

MAINTAIN THE REDUCTION:

dynamic traction

Answer 9

Various pulley systems used to apply dynamic traction

Question 10

CARE OF A PATIENT ON TRACTION

Answer 10

✓Check line of pull is parallel to shaft of fractured bone
✓Check that rope and weights are hanging freely
✓Check pin sites for signs of sepsis
✓Check that counter traction is applied if necessary
✓Check that the position of the patient relative to the traction is
correct
✓Check pressure areas
✓Check for all complications of immobilization. A patient on traction
is subject to all the usual complications of immobilization such as
DVT, chest complications, general deconditioning etc.

Question 11

SPLINTS, POP CASTS, SLINGS AND BRACES,

Answer 11

Splint = holds fracture steady but does not provide rigid fixation.
POP cast = sets hard around the limb and holds it straight and still, but
cannot maintain limb length
Sling = support injured upper limb
Cast Brace = supports limb and allows controlled joint motion

Question 12

what is the MOA of POP, risks, and advice for patients on POP?

Answer 12

MOA: 3 point pressure to maintain alignment
Usually include joints above and below #

RISKS: Initial risk of being too tight due to
swelling, later risk of being too loose due
to atrophy.

ADVICE TO PATIENTS WITH POP
✓Do not wet plaster
✓Never poke objects down POP to scratch as may break skin
✓POP should never be too loose or too tight, if so, return to doctor
✓Check skin around edges of POP for chaffing etc
✓Do not walk directly on POP, use plaster shoe
✓Return to the doctor immediately if the POP breaks
✓If the pain continues to increase, return to the doctor immediately

Question 13

TYPES OF SLINGS AND USES

Answer 13

Triangular – supports forearm and
elbow, takes weight off upper arm,
supports shoulder joint

Collar & Cuff – upper arm hangs free as
elbow not supported, gravity pulls on
shoulder and humerus

High Sling – keeps hand elevated, but
uncomfortable if forearm swollen,
++elbow flexion, risk of ulnar nerve
damage

Body Bandage – keeps arm tightly
pressed against chest wall

Question 14

OPEN REDUCTION:

Indications for internal fixation?

Answer 14

INDICATIONS FOR INTERNAL FIXATION
✓Too many/wide separation of fracture fragments
✓Fracture that is likely to unite poorly (delayed union or non-union)
✓Fracture cannot be reduced by closed manipulation
✓Inherently unstable fracture and prone to displacement
✓Pathological fractures
✓Large fragments involving a joint surface
✓Complications of fracture (multiple fractures, vascular and nerve
damage)
✓Early mobilisation of patient and limb is desired

Question 15

OPEN REDUCTION:

Disadvantages of internal fixation

Answer 15

DISADVANTAGES OF INTERNAL FIXATION 
✓Infection risk
✓Additional soft tissue trauma
✓Fracture site and haemotoma exposed, therefore increased 
interference with healing process
✓Must have good bone stock
✓Anaesthetic time longer
✓May need to remove hardware later on
✓Requires skilled surgeon
✓Risk of failure of implant
✓Plates require additional stripping of periosteum

Question 16

OPEN REDUCTION:

EXAMPLES OF INTERNAL FIXATION:

Answer 16

Screws – cortical or cancellous bone
-Used to compress plates against bone or to compress bone fragments
together

Plates-Used to maintain alignment of fracture fragments and compress bone
ends together. Usually applied on convex side of fracture.

Intra-medullary Nails- Usually used for fractures of the shafts of long bones.
The nail itself grips the inside of the medullary cavity and is load sharing. However, it is often necessary to lock the nail proximally and distally to prevent shortening and rotation at the fracture. Once the nail is locked, it becomes load-bearing and there is no axial compression of
the bone in between the locking screws. As the fracture heals, the surgeon may dynamise the nail by removing either the proximal or distal set of screws (those further from the fracture). The nail is now load sharing and slight axial compression may even aid the healing process.
The patient can usually start to weight bear at this point.
Intramedullary nails should always be removed once the fracture has
healed to allow normal axial loading of bone and prevent osteoporosis.
A disadvantage associated particularly with the use of intramedullary
nails, is the reaming of the intramedullary cavity prior to the insertion of
the nail. This disrupts the blood supply and has been associated with
delayed union and non-union.

Compression Screw-Plate

Cerclage and Tension Band Wiring- Tension band wiring results in compression of fracture fragments during muscle contraction.

Question 17

OPEN REDUCTOIN:

DISADVANTAGES ASSOCIATED WITH PLATES

Answer 17

o Wide exposure needed to gain access to fracture site causing
extensive soft tissue damage
o May be difficult to close skin over large plates
o Plate is more rigid than bone and is load bearing, causing
osteoporosis of underlying bone

Question 18

OPEN REDUCTION:
internal fixation:
DISADVANTAGES ASSOCIATED WITH WIRING

Answer 18

o Tension band wiring can slip or break, causing loss of reduction.
o Wires are often palpable under the skin and need to be removed at
a later stage.
o Cerclage wiring is not rigid.
o Cerclage wiring can strangle blood vessels in the periosteum and
constrict the healing bone.

Question 19

CLOSED REDUCTION

Indications for External fixation

Answer 19

EXTERNAL FIXATION (closed reduction)
INDICATIONS
✓Fracture associated with severe soft tissue damage
✓Several comminuted and unstable #s
✓Fractures of the pelvis which cannot be controlled quickly by any
other method
✓Fractures associated with nerve or vessel damage
✓Infected fractures for which internal fixation might not be suitable
✓Un-united fractures

Question 20

CLOSED REDUCTION

Complications of External Fixation

Answer 20

COMPLICATIONS
✓Damage to soft tissue structures
✓Over-distraction
✓Pin-track infection

Question 21

CLOSED REDUCTION

Advantages of External fixation

Answer 21

ADVANTAGES OF EXTERNAL FIXATION
✓Severe soft tissue injury and infected fracture sites – allows easy
access for wound cleaning and dressing, also minimized further
soft tissue damage during surgery.
✓Comminuted fractures can be held in good alignment.
✓Applied quickly, therefore useful in polytrauma patients.
✓Vascular and nerve damage can also be repaired quickly.
✓There is minimal interference with adjacent joints.
✓The frame can be adjusted later to improve alignment.
✓Allows for early mobilization of limb and patient.

Question 22

CLOSED REDUCTION

Disadvantages of External fixation

Answer 22

DISADVANTAGES OF EXTERNAL FIXATION
✓Very expensive.
✓Pin sites are sites of potential infection.
✓Not suitable for areas, best to insert pins through skin and bone
only.
✓Prone to delayed union if fragments held too far apart by rigid
fixation with no axial compression.

Question 23

PRINCIPLE: REHABILITATION OF FRACTURE

Answer 23

PREVENT AND TREAT COMPLICATIONS WHILE RESTORING
FUNCTION
Always assess and treat patient at highest functional level.
Must adhere to limitations imposed by nature of injury ie CONTRAINDICATIONS
Include all member of the medical team to ensure holistic management
of your patient.
-Prevent oedema
-Active exercise
-Assisted movement
-Functional activity

Question 24

OPEN FRACTURES INTIAL MANAGEMENT:

Answer 24

Appropriate treatment at the scene of accident is essential
After splinting, cover the wound with clean material and leave the
fracture site undisturbed until you reach hospital.
General assessment and life-threatening condition addressed
Tetanus prophylaxis is administered
Wound carefully inspected

Question 25

OPEN FRACTURES MANAGEMENT:

Gustilo’s Classification of Open Fractures

Answer 25

Gustilo Definition
Grade
I Open fracture, clean wound, wound <1 cm in length

II Open fracture, wound > 1 cm but < 10 cm in length without extensive soft-tissue
damage, flaps, avulsions

IIIA Open fracture with adequate soft tissue coverage of a fractured bone despite
extensive soft tissue laceration or flaps, or high-energy trauma (gunshot and farm
injuries) regardless of the size of the wound

IIIB Open fracture with extensive soft-tissue loss and periosteal stripping and bone
damage.
Usually associated with massive contamination. Will often need further soft-tissue
coverage procedure (i.e. free or rotational flap)

IIIC Open fracture associated with an arterial injury requiring repair, irrespective of degree of
soft-tissue injury.

Question 26

OPEN FRACTURES INTIAL MANAGEMENT:

Principles of treatment

Answer 26

Sterility and antibiotic cover
Debridement and wound excision
Wound closure
Stabilization of the fracture
Aftercare
Teamwork