Principles of Fracture

Management

Widiyatmiko

Introduction
Orthopaedics is
concerned with
bones, joints,
muscles, tendons and
nerves the skeletal
system and all that
makes it move

Introduction
Scope :

Congenital &
developmental
abnormalities

Infection & inflammation

Arthritis & rheumatic

disorders

Metabolic & endocrine

disorders

Tumours

Sensory disturbance &

muscle weakness

Injury & mechanical

derangement

Subdivision :
Traumatology
Orthopaedi :
1. Adult Reconstruction
2. Oncology
Orthopaedic
3. Pediatric Orthopaedic
4. Spine
5. Hand & Microsurgery
6. Sports Injury

In Emergency Room
Assess all trauma patient for possibility of orthopaedic case!
If the patient need operation prepare as soon as possible!
1. Informed consent
2. Tell to fast at least 6 hours prior to op
3. Make IV line
4. Tetanus prophilactic
5. Antibiotic & analgetic
6. Blood check (SYSMEX for < 40 y.o, complete for > 40 y.o and < 14
y.o)
7. Urine check
8. Cross match & blood reservation in blood bank
9. EKG ( for > 40 y.o)
10. Chest X-Ray, with expertise for < 14 y.o
11. Complete the medical record ! (under resident supervision)
12. IPD or paediatric consultation ( for > 40 or < 14, sometimes no
need)
13. Anesthesiology consultation

General Principles of Fracture

Treatment
1. First, Do No Harm
2. Base Treatment on Accurate Diagnosis
and Prognosis
3. Select Treatment with Specific Aims
4. Cooperate with the Laws of Nature
5. Make Treatment Realistic and Practical
6. Select Treatment for You as an
Individual

Aphorism of Fracture
Management
1. Think before you start. Are you
treating the patient? Or merely the x
ray?
2. Think before you reduce. Have you
worked out how to do it? And how to
hold your reduction?
3. Think before you hold. Is your splint
necessary? Is it harmful?
4. Think before you operate. Are you
good enough? Are your facilities good
enough?

What is fracture ?
Fracture is a break or disruption in
the continuity of a bone.
Fracture divide in 2 types :
Closed fracture
Open fracture

Fracture Description
Anatomic location includes the name of the bone or the bones
involved.
Regional location diaphysis ,metaphysis ,epiphysis;
intraarticular or extraarticular and physis.
Directions of the fracture lines transverse ,oblique and
spiral.
Conditions of the bone comminution # ,pathological #
,incomplete # ,segmental # ,fracture with bone loss ,fracture with
butterfly fragment ,stress # and avulsion #
Extent Fracture may complete or incomplete
Relationship of the fracture fragments to each other
undisplaced or displaced
eg:translated,angulated,rotated,distracted,overriding and
impacted.

Examination of The Affected Parts

First We LOOK
Then We FEEL
Then We MOVE

Neurological examination
Diagnostic imaging
Blood Test
Synovial fluid analysis
Bone biopsy
Arthroscopy
Electro diagnosis

Adult and Children Fracture

Children Fracture
1.
2.
3.
4.
5.
6.
7.
8.
9.

Fracture more common .

Stronger and more active periosteum .
More rapid fracture healing .
Special problems of diagnosis .
Spontaneous correction of certain residual
deformities .
Differences in complications .
Different emphasis on methods of treatment
Torn ligament and dislocation less common .
Less tolerance of major blood loss

Adult Fracture
1.
2.
3.
4.
5.
6.
7.
8.
9.

Fracture less common but more serious .

Weaker and less active periosteum .
Less rapid fracture healing .
Fewer problem of diagnosis .
No spontaneous correction of residual
fracture deformities .
Differences in complication .
Differences emphasis on methods of
treatment.
Torn ligament and dislocations are more
common .
Better tolerance of major blood loss .

CLOSED FRACTURE
The fracture is not exposed to

the

external environment.

The soft tissue injury ranges

from minor to massive .

Closed soft tissue injury are

commonly graded by the

methode of Tscherne (grade 0
until grade 3 )

TREATMENT
Protection Alone without
reduction or immobilization
Immobilization by External
Splinting without reduction
Closed Reduction by Manipulation
Followed by Immobilization
Closed Reduction by Continuous
Traction Followed by
Immobilization
Closed Reduction Followed by
Functional Fracture Bracing

TREATMENT
Closed Reduction by manipulation
Followed by External Skeletal
Fixation
Closed reduction by Manipulation
Followed by Internal Fixation
Open Reduction Followed by
Internal Skeletal Fixation
Excision of a Fracture Fragment
and Replacement by an
Endoprosthesis

OPEN FRACTURE
The fracture is exposed to the
external environment.
The amount of soft tissue
destruction is related to the
level of energy imparted to the
limb during the traumatic
episode.
Describe with GustilloAnderson grading system.

OPEN (COMPOUND)
FRACTURES
Goals
Prevention of infection
Healing of the fracture
Restoration of function

Steps in management
ABC included resucitation and
immobilisation
Assess neurovascular status of
the limb
Swab wound
Photograph & Cover wound
Tetanus prophylaxis
Give IV antibiotics

 1 . All open fractures are treated as emergencies.

2. Most studies demonstrate that cultures
obtained on admission are of little help. The
most important cultures are obtained after
initial surgical debridement.
3. The basic prophylactic antibiotic should be a
broad spectrum cephalosporin.
4 . Generally, primary closure should not be
formal but may be considered in Grade I
fractures only if adequate debridement and
irrigation have been done. Delayed primary
closure at 5 to 7 days is performed in Grade II
and Grade III injuries.

 5. If there is any doubt about adequate

debridement, LEAVE THE WOUND
OPEN!!! THOROUGH DEBRIDEMENT
AND COPIOUS IRRIGATION is
mandatory in the initial treatment of all
open fractures. For Grade II and III
fractures, generally use pulsatile jet
lavage. Exception for soft tissue injuries
which can compromise wound coverage
if there is swelling of the tissue. This is
not a reason to not clean the wound- a
toothbrush can be used on the exposed
bone.

 6. Rigid stabilization of fractures

is indicated in Grade III

fractures and many types of
fractures in polytraumatized
patients. The type of fixation
should be determined by the
resident and the staff based on
the nature of the injury and bone
involved.

WHAT IS POLYTRAUMA ?

Objectives
Establish the principles for assessing
the patient with musculoskeletal
injuries.
Establish treatment priorities.
Identify the importance of
musculoskeletal injuries in the
multiply injured patient.

Emergency in Orthopaedic
Emergency : trauma cases
- Life threatening
- Limb treatening
85 % of blunt trauma
affect musculoskeletal
system
Life saving before limb
saving

Key Questions
How do musculoskeletal injuries
impact on the primary survey?
What are my priorities?
What are my management
principles?

Assessment of the Polytrauma

Patient
Primary Survey
A irway with cervical spine control
B reathing
C irculation with control of hemorrage
D isability (neurological state)
E xposure (take the patient clothes off)

Primary survey
management
The 3 Ss
Stop the bleeding!
Splint the extremity
Stabilize the pelvis

Primary Survey &

Resuscitation
Recognize and control hemorrhage
Direct pressure
Splint fractures
Fluid resuscitation
BE AWARE OF REPERFUSION INJURY!

Primary Survey &

Resuscitation
Adjuncts : Fracture immobilization
Goals
Hemorrhage control
Pain relief
Prevent further soft tissue injury
Apply splint early, but avoid delay in
resuscitation.
Be careful in dislocation

Primary Survey & Resuscitation

Adjuncts : X-Rays

Determinited by patients condition

Obtain AP pelvis early if

hemodynamically abnormal and no
obvious source of bleeding

Secondary Survey

History

AMPLE

From Head to toe examination

Every orifice must be examined
Dont forget the back!

Secondary
Survey
Look
Feel
Listen
For What?

For What?
Look
Deformity
Pain
Tenderness
Wound(s)

Feel
Crepitus
Skin flaps
Neurologic
deficit
Pulses

Listen
Doppler signals
Bruit

Life- Threatening
Injuries

Major pelvic disruption with

hemorrhage
Major arterial hemorrhage
Crush syndrome (rhabdomyolysis)

Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Posterior pelvic structures disrupted
Pelvis open : vessels, nerves,rectum,
skin
Mechanism of injury
Motorcycle
Pedestrian
Crush
Falls > 12 feet (3.6 meters)

Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive
Bleeding

Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive
Bleeding

Pelvic
Wrapping

Life Threatening
Musculoskeletal Trauma
Main Arterial Rupture
1. Trauma
- sharp, blunt
2 Examination
- Artery pulse, Doppler
- Ankle / brachial index
3. Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint

Life Threatening
Musculoskeletal Trauma
Crush Syndrome

Myoglobinuria
Metabolic acidosis, K,
Ca and coagulopathy
Compartment syndrome
IV fluids, alkalization of
urine

Limb- Threatening
Injuries

Open fracture and joint injuries

Vascular injuries
Compartment syndrome
Neurologic injury

What are my early

concerns?
Vascular compromise
Open fractures

Limb Threatening
Musculoskeletal Trauma
Open Fractures

Apply appropriate splint

Cleanse / debride (now or later)
Consider time factor
Obtain orthopaedic consult

Limb Threatening
Musculoskeletal Trauma
Open Fractures
Classifying the injury
Gustilos classification (Gustilo et al,
1990)

Open Fracture grade 1

Open Fracture grade 2

Open Fracture grade 3A

Open Fracture grade 3B

Open Fracture
grade 3C

Limb Threatening
Musculoskeletal Trauma
Open Fractures

Principles of treatment
Objectives :
- Prevention of infection
(sepsis/osteomyelitis)
- Promote bone healing
- Restoration of function

Limb Threatening
Musculoskeletal Trauma
Open Fractures

Principles of treatment
4 essentials are :
1. Wound irrigation & debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound coverage

Open Fracture
Complicated
case
Not proper initial management

Limb Threatening
Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

Reduce fracture(s)
Splint fracture(s)
Assess by Doppler
Obtain consult (time
is critical)
Consider
angiography

Limb Threatening Musculoskeletal Trauma

Vascular Trauma & Traumatic Amputation

Limb Threatening Musculoskeletal Trauma

Vascular Trauma & Traumatic Amputation
Management
Muscle necrosis : 6 h
Warm & Cold
Ischemic
Reimplatantation &
Revascularization
Proper amputee
management!

Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Fractures of the arm or leg
ischemia
Infarcted muscles fibrous tissue
(Volkmanns ischemic contracture)

Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome

Clinical features
Elbow, forearm bones, 1/3
prox. of tibiae, multiple
fractures of the foot or hand,
crush injuries &
circumferential burns
Five Ps
The presence of a pulse does
not exclude the diagnosis
Be careful in unconscious
patient !

Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Treatment
Decompression
Open fasciotomi

Limb Threatening
Musculoskeletal Trauma
Dislocations

Displacement of bone from normal joint

Location : hip, shoulder, elbow, finger,
patella, knee, ankle, acromioclavicular
Sign : loss of normal shape &
loss of movement

Posterior Hip Dislocation

Neurologic Injury

Due to fracture /dislocation

Posterior shoulder : Axillary nerve
Posterior hip : Sciatic nerve
Recognize injury and immobilize
Early orthopaedic consult
Careful reduction, if possible
reassess and splint

Limb Threatening
Musculoskeletal Trauma
Massive skin avulsion

Abdominal flap
following skin avulsion
of the hand

Limb Threatening Musculoskeletal Trauma

Massive skin avulsion

Kelirumologi in Fracture
Management

Pitfalls

Occult injuries
Occult blood loss
Compartment syndrome

Case 1 : Male, 40 y.o

ICD 9-CM 79.63, 93.44

Question

Summary

Primary Survey : Identify lifethreatening

Injuries
Secondary Survey : Identify limbthreatening injuries
Mechanism of Injuries : History
important
Orthopaedic consult
Early immobilization