Download General principles of fractures IV

General principles of fractures
IV
Exercise
 More correctly 'restore function' - not only to the
injured part but also to the patient as a whole. The
objectives are to reduce oedema, preserve joint
movement, restore muscle power and guide the patient
back to normal activity.
Exercise
 Prevention of oedema swelling is almost inevitable
after a fracture and may cause skin stretching and
blisters. Persistent oedema is an important cause of
joint stiffness, especially in the hand; it should be
prevented if possible, and treated if it is already
present, by a combination of elevation and exercise.
Exercise
 Not every patient needs admission to hospital, and less
severe injuries of the upper limb are successfully managed by
placing the arm in a sling: but it is then essential to insist on
active use, with movement of all the joints that are free. With
most closed fractures, all open fractures and all fractures
treated by internal fixation it must be assumed that swelling
will occur: the limb should be elevated and active exercises
begun as soon as the patient will tolerate this.
Exercise
 Elevation an injured limb usually needs to be elevated;
after reduction of a leg fracture the foot of the bed is
raised and exercises are begun. If the leg is in plaster
the limb must, at first be dependent for only short
periods.
Exercise
 Active exercise Active movement helps to pump away
oedema fluid, stimulates the circulation, prevents softtissue adhesion and promotes fracture healing. A limb
encased in plaster is still capable of static muscle
contraction and the patient should be taught how to do
this. When splintage is removed the joints are mobilized
and muscle-building exercises are steadily increased.
Exercise
 Assisted movement passive movement should
avoided because it might lead to myositis ossificans
especially with injuries around the elbow. Certainly
forced movement should not be permitted but gentle
assistance during active exercises may help to retain
function or regain movement after fractures.
Open fractures
 General consideration
 Many patients with open fractures have multiple
injuries and severe shock; for them appropriate
treatment at the scene of the accident is essential.
The wound should be covered with a sterile dressing
or clean material and left undisturbed until the
patient reaches the accident department.
Open fractures
 In hospital a rapid general assessment is the first step,
and any life- threatening conditions are addressed. The
wound is then inspected; ideally it should be
photographed, so that it can again be covered and left
undisturbed until the patient is in the operating theatre.
Open fractures
 Four questions need to be answered:
 (1) What is the nature of the wound?
 (2) What is the state of the skin around the wound?
 (3) Is the circulation satisfactory?
 (4) Are the nerves intact?
Open fractures
 All open fractures, no matter how trivial they may seem,
must be assumed to be contaminated; it is important to try
to prevent them from becoming infected. To this end the
four essentials are:
 (l) Immediate wound cover
 (2) Antibiotics prophylaxis;
 (3) Early wound debridement; and
 (4) Stabilization of the fracture.
Open fractures
 Classification
 Gustilo’s classification of open fracture 1990
 Type I The wound is usually a small, clean puncture
through which a bone spike has protruded. There is
little soft-tissue damage with no crushing and the
fracture is not comminuted.
Open fractures
 Type II The wound is more than 1 cm long, but there is
no skin flap. There is not much soft- tissue damage, and
no more than moderate crushing or comminution of the
fracture.
Open fractures
 Type III There is extensive damage to skin, soft tissue
and neurovascular structures, with considerable
contamination of the wound. There are three grades of
severity
 Type IIIA the fractured bone can be adequately
covered by soft tissue.
Open fractures
 Type IIIB there is also periosteal stripping, as well as'
severe comminution of the fracture;
Open fractures
 Type III C if there is an arterial injury which needs to
be repaired, regardless of the amount of other softtissue damage. High-velocity injuries are classified as
IIIB or C; although the wound is small, internal
damage is severe.
Open fractures
 The incidence of wound infection correlates directly
with the extent of soft-tissue damage, rising from less
than 2% in type I to over 10% in type II fractures.
Open fractures
 Early management
 The wound should be kept covered until the patient
reaches the operating theatre. Antibiotics are given
as soon as possible. no matter how small the
laceration and are continued until the danger of
infection has passed. In most cases a combination of
benzyl penicillin and flucloxacillin given 6 hourly for
48 hours will suffice;
Open fractures
 if the wound is heavily contaminated, it is prudent to
cover also for Gram- negative organisms by adding
gentamicin or metronidazole and to continue treatment
for 4 or 5 days. Tetanus prophylaxis is equally important:
toxoid for those previously immunized, human
antiserum if not.
Open fractures
 Debridement
 The operation aims to render the wound devoid of
foreign material and of dead tissue, leaving a good
blood supply throughout. Under general anesthesia the
patient’s clothing is removed, while an assistant
maintains traction on the injured limb and holds it still.
Open fractures
 The dressing previously applied to the wound is
replaced by a sterile pad and the surrounding skin is
cleaned and shaved. The pad is then taken off and the
wound is irrigated thoroughly with copious amounts
of physiological saline; the final irrigation may be with
an antibacterial agent such as bacitracin.
Open fractures
 A tourniquet is not used because it would endanger
the circulation still further and make it difficult to
recognize which structures are devitalized. The
tissues are then dealt with as follows.
Open fractures
 Skin Only small strip from the skin edge is excised
from the wound (much skin as possible is spared). The
wound often needs to be extended by planned incisions
to obtain adequate exposure: .once it is enlarged
clothing and other foreign material may be picked out.
Open fractures
 Fascia is divided extensively so that the circulation is
not impeded.
 Muscle Dead muscle is dangerous; it provides food for
bacteria. It can usually be recognized by its purplish
discoloration. Its mushy consistency, its failure to
contract when stimulated and its failure to bleed when
cut. All dead and doubtfully viable muscle is excised.
Open fractures
 Blood vessels large bleeding vessels are tied
meticulously.
 Nerves it is usual best to leave a cut nerve
undisturbed. It should be left for secondary suture.
 Tendons as a rule, cut tendon also should left for
secondary suture
Open fractures
 Bone the fracture surfaces are gently cleaned and
replaced in the correct position. Bone like skin, should
be spared and fragments removed only if they are small
and totally detached.
Open fractures
 Joint Open joint injury are best treated by wound
toilet, closure of synovium and capsule and systemic
antibiotics; drainage or suction irrigation is used only if
contamination is severe.
Open fractures
 Wound closure
 To close or not to close the skin - this can be a difficult
decision. A small, uncontaminated type I wound, operated on
within a few hours of injury may after debridement, be
sutured (provided this can be done without tension) or skin
grafted. All other wounds must be left open until the dangers
of tension and infection have passed. The wound is packed
with sterile gauze and is inspected after 5 days: if it is clean, it
is sutured or skin grafted (delayed primary closure).
Open fractures
 Stabilization of the fracture
 It is now recognized that stability of the fracture is
important in reducing the likelihood of infection. For
type I or small type II wound with a stable fracture a
widely split plaster is permissible or, for the femur,
traction on a splint but more severe wounds (and
gunshot wounds) need to have the fracture fixed more
securely.
Open fractures
 The safest method is external fixation. Intramedullary
nailing (with locking if the fracture is comminuted) can
be used for the femur or tibia. Plates and screws can be
used for metaphyseal or articular fractures, but only if
the surgeon is experienced in their use and the
circumstances are ideal.