Principle of CLOSED

fracture management
1. Reduction
2. Hold
3. Exercise

1. Reduction
Aim for adequate apposition and normal
alignment of bone fragment.
3 methods of reduction:
a) Manipulation
b) Mechanical traction
c) Open operation
Reduction is unnecessary when:
) Little or no displacement
) Displacement does not matter (eg: clavicle
fracture)
) Reduction unlikely to succeed (eg: compression
fractures of vetebrae)

a) Manipulation
Suitable for:
For all minimally displaced fracture
Most fracture in children
Fracture that are likely to be stable after
reduction
Under anesthesia and muscle relaxation,
the fracture is reduced by 3 fold maneuver:
1. The distal part of the limb is pulled in the line of
the bone.
2. As the fragments disengage, they are
repositioned.
3. Alignment is adjusted in each plane.

Colles' Fracture:
Reduction
by Manipulation

b) Mechanical traction
Used in :
Some fractures are difficult to reduce by
manipulation because of powerful muscle pull
(eg:Fracture of femoral shaft)
In some cases, rapid mechanical traction is applied
prior to internal fixation

c) Open operation
Indicated in :
When closed reduction failed.
Large articular fragment needs accurate
positioning.
Avulsion fractures in which the fragments
are held apart by muscle pull.
When the operation is needed for another
injuries (e.g. arterial damage)
When a fracture will need internal fixation to
hold it.

2) Hold
Function of distriction of movement :
prevention of displacement
Decrease the pain
Promote soft-tissue healing
Allow free movement of the unaffected parts
5 Methods:
a) Sustained traction
b) Cast splintage
c) Functional bracing
d) Internal fixation
e) External fixation

a) Sustained traction

Traction is applied to the limb distal to the fracture,

so to exert continues pull in the long axis of the bone.

Particularly useful for spiral fracture of long bone

shaft, which are easily displaced by muscle
contraction

Sustained lower limb traction keeps the patient in

bed for long time, thus increasing the risk of
complications such as thromboembolism, respiratory
problem and general weakness.

Sustained traction is best avoided in elderly patients.

Type of traction
1. Traction by
gravity

2. Balanced
traction
- Skin traction
- Skeletal
traction

3. Fixed
traction

Gallows traction

b) Cast splintage

Plaster of Paris is still widely used as a splint specially

for distal limb fracture and for most children's fractures.
Its safe & the speed of union is the same as
traction but the patient can go home sooner.
The main drawback is joint stiffness from adhesions
after swelling and hematoma resolution.
This is minimized by delayed splintage or starting with
conventional cast but after a few weeks replace the cast
by a conventional brace which permits joint movement.

Complications:
Compartment Syndrome
Pressure sore
Skin abrasion and laceration

c) Functional bracing
By using POP to prevent joint stifness while still
permitting fracture splintage and loading
Segments of a cast are applied only over the
shafts of the bone, leaving the joint free,
connected by metal or plastic hinges which allow
movements in one plane.
Used for fracture of the femur or tibia, or fracture
begin to unite i.e. after 3-6 weeks of traction or
restrictive splintage .

d) Internal fixation
Bone fragments may be fixed with screws, pins or nails, a
metal plate held by screws, a long intramedullary nail,
circumferential bands, or combination of these.
Indications:
1. Fractures cant be reduced except by operation.
2. Unstable fractures and those prone to re-displacement
after the reduction.
3. Fractures that unit poorly and slowly (e.g. femoral neck).
4. Pathological Fractures.
5. Multiple fractures.
6. Fractures in patients who present severe nursing
difficulties .
Complications:
.Infection
.Nonunion
.Implant failure
.Refracture

Types of internal fixation:

1. Screws:
useful for fixing small fragments into the main
bone.

2. Wires:
used when fracture healing is predictably
quick.

3. Plates & Screws:

useful for treating metaphyseal fractures of
long bone and diaphyseal fracture of the
radius and the ulna.

4. Intramedullary Nails:
suitable for long bones, locking screws are
introduced to resist any rotational force.

e) External fixation

The bone is transfixed above & below the fracture with screws
or pins or tensioned wires & these are clamped to a frame, or
connected to each other by rigid bars.
Indications:
1. Fracture associated with severe soft-tissue damage where
the wound can be left open for inspection, dressing or
coverage.
2. Severely comminuted & unstable fractures.
3. Fracture associated with nerve or vessel damage
4. Fracture of the pelvis, which can't be controlled be any other
methods.
5. Infected fractures, which internal fixation might not be
suitable.
6. Ununited fractures, where dead fragments can be removed
and the remaining ends brought together in the external
fixator.
.Complications:
Damage to soft-tissue structures

3) Exercise

Reduce edema

Stimulates the circulation so promotes

fracture healing & prevents soft-tissue
adhesion

Preserve joint movement

Restore muscle power

Guide the patient back to normal activity