FRACTURE ESSENTIALS AND ADVANCED ORTHOPAEDIC TRAUMA MANAGEMENT
What is a fracture?
A fracture is defined as a disruption in the integrity of a living bone, involving injury to the bone marrow, periosteum, and adjacent soft tissues.
How does a fracture occur?
Fractures occur when the force applied to a bone exceeds the strength of the involved bone. Bones can fracture as a result of direct or indirect trauma. Direct trauma consists of direct force applied to the bone like tapping fractures (bumper trauma in road accidents), penetrating fractures (eg, gunshot wound) and crush fractures. Indirect trauma involves forces acting at a distance from the fracture site such as tension (traction), compressive, and rotational forces.
What is the accident scenario in India?
Fracture incidence is multifactorial and often complicated by such factors as the patient’s age, sex, co-morbidities, lifestyle, and occupation. Nearly 1.05 lakh people die in road accidents in India. Interestingly, there was a bimodal distribution of fractures in males, with a high incidence in young men and a second rise in men starting at the age of 60 years. In women, there was a unimodal distribution of fractures, with a rise around the time of menopause.
What are the goals in fracture treatment?
Restore the patient to optimal functional state, Prevent fracture and soft-tissue complications, Get the fracture to heal and in a position which will produce optimal functional recovery and Rehabilitate the patient as early as possible
How does an orthopaedic surgeon describe a fracture?
- Mechanism of injury (traumatic, pathological, stress)
- Anatomical site (bone and location in bone)
- Configuration Displacement : three planes of angulation, translation and shortening
- Articular involvement/epiphyseal injuries : fracture involving joint, dislocation and ligamentous avulsion
- Soft tissue injury
What are the complications of fractures?
General Other injuries, Chest infection, Embolism, UTI, ARDS, Bed sores
Bone Infection, Non-union, Malunion, Avascular necrosis
Soft-tissues Plaster sores/Wound Infections, Tendon rupture, NeuroVascular injury, Nerve compression, Compartment syndrome, Volkmann contracture
What are the factors affecting fracture healing?
- It depends on the energy transfer of the injury, the tissue response and the method of treatment.
- The patient factors include age, nutritional status, systemic diseases, hormonal factors and personal habits of smoking and alcoholism.
What is the time duration for fracture healing?
Fracture healing depends on many factors and varies considerably. In general, fracture healing, for adults, upper limb in 6-8 weeks and lower limb in 12-16 weeks and for child, upper limb in 3-4 weeks and lower limb in 6-8 weeks. Radiologically, on X-ray fracture healing is shown by Bridging callus formation and bone remodelling
What are the types of trauma or fracture presentation?
Single-limb injury
This consists of patients where only either single long or small bone is fractured. Management depends on individual fracture considerations.
Multiple traumatic injuries (polytrauma)
These poly-trauma or multiply injured patients need much urgent attention. These patients could have life threatening associated injuries and need multi-disciplinary approach.
The initial assessment of a patient with polytrauma follows the advanced trauma life support (ATLS) protocol and includes the identification and treatment of life-threatening injuries. The first step is evaluation of the individual’s airway, breathing, and circulation. Once the patient is hemodynamically stable, the secondary survey, a complete systems-based physical examination, is performed.
These patients need higher tertiary care hospital management. Patients should be shifted to advanced trauma care units for intensive management where advanced infrastructure, equipments, facilities, specialist and super-specialists are available.
Management includes Life saving measures to Diagnose and treat life threatening injuries and Emergency orthopaedic involvement.
What is the Initial management of fractures?
The initial management of fractures consists of realignment of the broken limb segment and then immobilizing the fractured extremity in a splint. The distal neurologic and vascular status must be clinically assessed. Splinting is critical in providing symptomatic relief for the patient. Patients should receive adequate analgesics.
What is an open fracture?
An open fracture is a broken bone that penetrates the skin. Open fractures are typically caused by high-energy injuries such as car crashes, falls, or sports injuries. Furthermore, because of the risk of infection, there are more often problems associated with healing when a fracture is open to the skin.
What are the management protocols of open fractures?
Hemostasis should be obtained, followed by antibiotic administration and tetanus vaccination. Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory. The wound is subsequently stabilized either temporarily or definitively. If soft-tissue coverage over the injury is inadequate, soft-tissue transfers or free flaps are performed when the wound is clean and the fracture is definitively treated.
What are the methods of fracture treatment?
Fracture management can be divided into non-operative and operative techniques. The non-operative technique consists of a closed reduction if required, followed by a period of immobilization with casting or splinting. Closed reduction is needed if the fracture is significantly displaced or angulated.
What are indications for operative treatment?
General trend toward operative treatment last 30 yrs with improved implants and antibiotic prophylaxis and use of closed and minimally invasive methods
Current absolute indications:-
Polytrauma, Displaced intra-articular fractures, Open fractures, Fractures with vascular injury or compartment syndrome, Pathological fractures, Malunion and Non-unions
Current relative indications:-
Loss of position with closed method, Poor functional result with non-anatomical reduction, Displaced fractures with poor blood supply, Economic and medical indications
What is the Rehabilitation protocol after fracture?
Restoring the patient as close to pre-injury functional level as possible.
Approach needs to be pragmatic with realistic targets. Multidisciplinary involvement of Physiotherapist, Occupational therapist, nurse, General Practitioner and Social worker is needed.
HIP FRACTURE IN ELDERLY
Fractures of the hip are relatively common in adults and often lead to devastating consequences. Disability frequently results from persistent pain and limited physical mobility. Hip fractures are associated with substantial morbidity and mortality. Most hip fractures occur in elderly individuals as a result of minimal trauma, such as a fall from standing height. 50% of post hip fracture patients require permanent use of assistive devices or aids for walking
Basic principles in management of hip fractures
Surgery is needed in almost all cases of fracture neck femur, except few undisplaced fractures. The treatment of femoral neck fractures primarily depends on a careful assessment of patient’s age, co-morbidities and activity level, bone quality and fracture pattern. All patients must be evaluated thoroughly and their condition stabilized prior to proceeding with internal fixation of the femoral neck fracture.
Early surgery (within 24-48 hr) is associated with a reduction in 1-year mortality and lower incidence of pressure sores, confusion, and fatal pulmonary embolism
Treatment Options for Elderly Patients
- DHS – ( dynamic hip screw) / cannulated screws
- Intra-medullary nail (Proximal femoral nail)
- Hemi arthroplasty (uni or bipolar)
- Total hip arthroplasty
Strategies for Preventing Hip Fractures
- Proven Fall Prevention Strategies: Exercise, Environmental modifications, Education, Medication reviews, Clinical Interventions and Multi-factorial interventions
- Enhancing Bone Density: Exercise, Sunshine, Treatment of osteoporosis or osteopenia, medical regimens for calcium and vitamin D, Bisphosponate alendronate or calcitonin.
COMPLEX PELVI-ACETABULAR INJURY
With ever increasing economic and energy crisis, frequency of high velocity injuries is increasing. High energy pelvic ring disruptions and acetabular fractures results from significant traumatic event and are associated with a variety of primary organ system injuries. Pelvic injuries account 3% of all reported fractures with mortality rates of 6-20%. Acute pelvic fractures are potentially lethal, even with modern techniques of polytrauma care. Haemodynamic stabilization of the patient and the treatment of organic lesions must be the first priorities in the interdisciplinary therapy.
Acetabular fractures are a particular challenge even compared with other joint fractures. The major problems in the acetabulum are complicated anatomy, making exposure of the fracture difficult and severe comminution of the fractures, making reduction and fixation of the fracture difficult. Also fractures of the acetabulum occur in poly-traumatized patient with major associated injuries and have a disability rate that is high no matter what the treatment.
ILLIZAROV SURGICAL ADVANCES
What are the advantages in Illizarov Surgery?
This technique has many advantages such as; minimal trauma, no need to open the fracture site, optimal biomechanical stability (eliminates rotational and binding forces, allows pure compressive forces), possibility to reconstruct large bone defects, correction of deformities, providing early joint motion, keeping the blood supply of the bone, and minimal blood loss during the operation.
How does Leg Lengthening Illizarov surgery work?
It involves one or more of the bones in a limb being broken, and then the two separate parts of that bone being slowly pulled apart (distracted). Normally this involves small adjustments done several times a day. Bone regenerates in this situation, and new bone cells will be produced and will fill the space in the break. The new bone will not be fully hardened (consolidate) for over a year, but should be strong enough to support walking within a few months of surgery.
Most surgeons recommend a maximum of 5cm per limb, but up to 12cm is possible with some techniques. For an increase of 5cm (50mm) a normal, healthy adult should expect the whole process to take about 6 months from operation, to being able to walk again. There are no long term effects on the lengthened bone, as bone is under constant remodeling; hence the newly formed bone is as strong as the intact original bone.
