FRACTURE MANAGEMENT IN

EMERGENCY

BY- DR ABHISHEK GARG

MS Orthopaedics
PRE HOSPITAL MANAGEMENT-

• Organization
• Safety on scene – including personal protection
• Immediate actions and triage
• Assessment and initial management - awareness, recognition and management (ARM)
• Extrication and immobilization
• Transfer to hospital
• Helicopters and air ambulances.
GOLDEN HOUR-

• Rapid transport of severely injured patient to the trauma centre

• Chances of survival diminishes rapidly after 1 hour.

• 3 fold increase in mortality after 30 minutes of elapsed time without care in severely,

multiply injured patients

HOSPITAL MANAGEMENT

• Organization- receiving hospitals, trauma units (Level 2) and major trauma centres (Level 1)

• Trauma teams- includes Emergency Department physician ,physician anaesthetist and anaesthetic technician ,

Emergency Department nurses, radiographer ,surgeon from general surgery and orthopaedics, intensive care

specialists, other appropriate specialists

• Assessment and management – the ATLS concept (Primary survey and simultaneous resuscitation, secondary

survey, definitive care)

• Initial assessment and management

• Definitive, systemic management.

 PRIMARY SURVEY

The aim of is to identify all immediately life-threatening conditions and commence treatment following Cabcde

c - Control exsanguinating external hemorrhage

A - Airway with cervical spine control
B - Breathing
C - Circulation
D - Disability assessment
E - Exposure and temperature control
 PRINCIPLES

• REDUCTION, IMMOBILISATION AND REHABILITATION

• Plain x-rays- 2 planes,2 joints, with traction

• Additional investigations- CT scan for the imaging of intraarticular fractures, information on the size,

location, and displacement of fracture fragments

• MRI- useful in cases of a combined bone and soft-tissue injury (eg, tibial plateau fracture with

meniscal and ligament injury).

• Full evaluation of the fracture will allow classification and surgical planning
 SECONDARY SURVEY

• A full history of the accident.

• A medical and drug history.

• A thorough examination from head to toe, front and back, should identify remaining injuries

• Each bone and joint should be tested for tenderness and stability.

• Neurovascular assessment

• All wounds inspected and any gross contaminants removed. (photographs- if possible)

• Appropriate tetanus coverage and antibiotics

• X-rays of all suspected fractures must be obtained.

• TYPES – open and closed fractures depending on the break in continuity of overlying skin.

• Mechanism- injury, repetitive stress, pathological fractures

• Clinical features- pain and tenderness, swelling, deformity, crepitus, loss of function, nerve or

vascular injury

• Classification- on the basis of anatomical location, fracture line, mechanism of injury, comminution,

condition of overlying structures.

• Trauma- DIRECT(tapping, crushing or high/low velocity injuries) and INDIRECT (tension, rotational,

angulation, compression)
 TREATMENT OF CLOSED FRACTURES

• Includes manipulation to improve the position of the fragments, followed by splintage to hold them

together until they unite; meanwhile joint movement and function must be preserved.

• Fracture healing is promoted by physiological loading of the bone, so muscle activity and early partial or full

weight-bearing are encouraged (rehabilitation).

• The most important factor in determining the natural tendency to heal is the state of the surrounding soft

tissues and the local blood supply.

The more severe grades of injury are more likely to require some form of mechanical fixation; good skeletal stability aids
soft-tissue recovery.
Situations in which reduction is unnecessary:

(1) when there is little or no displacement

(2) when displacement does not matter initially (e.g. in fractures of the clavicle)

(3) when reduction is unlikely to succeed (e.g. with compression fractures of the vertebrae).

• Reduction should aim for adequate apposition and normal alignment of the bone fragments.

• Articular surface should be reduced as near to perfection as possible (abnormal load distribution between the surfaces

and predispose to degenerative changes in the articular cartilage.)

CLOSED REDUCTION- restore length, rotation and alignment

• For minimally displaced fractures, fractures in children, or those that can be held in

some form of splint/cast.

• The distal part of the limb is pulled in the line of the bone- fragments disengage-

repositioned- alignment adjusted in each plane

• soft-tissue strap prevents overreduction and stabilizes the fracture

• fractures difficult to reduce (powerful muscle pull) - may need prolonged traction
DEFINITIVE TREATMENT

• CONSERVATIVE- IN CLOSED, UNDISPLACED FRACTURES THAT ARE REDUCIBLE

• SURGICAL- ORIF/CRIF, PERCUTANEOUS PINNING, EXTERNAL FIXATION

OPEN REDUCTION

• when closed reduction fails (difficulty in controlling the fragments or soft tissues interposition)

• large articular fragment (needs accurate positioning)

• for traction (avulsion) fractures in which the fragments are held apart
 The available methods of holding reduction are:

• continuous traction
• cast splintage
• functional bracing
• internal fixation
• external fixation

 Contraindications to non-operative methods are-

• inherently unstable fractures

• multiple fractures
• fractures in confused or uncooperative patients.
 CONTINUOUS TRACTION

• TYPES- traction by gravity (only for upper limb), skin and skeletal traction.
• In skin and skeletal traction- fixed, balanced or combination.
• Complications- circulatory issues, nerve injury, pin site infections, growth plate damage, distraction,
redisplacement

CAST SPLINTAGE
• In shaft fractures, three-point pressure can be applied to keep the intact periosteal hinge under tension and thereby
maintain reduction- Check xray
• Split if injury is recent, expose skin
• Upper limb- position of splinted joints varies with the fracture.
• Splintage continued until the fracture is consolidated (functional brace may be substituted)
• Complications- Prevent tight/loose cast, pressure sores, skin abrasion/laceration, joint stiffness, Prevent bony
prominences with wool, compartment syndrome, allergy
• Casting continues with application of stockinette, then circumferential application of two or three
layers of cotton padding, and finally circumferential application of plaster or fiber-glass.
• In general, 2- to 4-inch padding for the upper extremities and 4- to 6-inch padding for the lower
extremities
• As the cast hardens the surgeon should manipulate the fracture, taking care not to indent the cast
material, thereby compressing the underlying soft tissue.
• Care must be taken not to obstruct joint motion or, if a joint is encased by the cast, it should be
placed in the correct position.
• Once the cast has been applied, radiographs should be obtained to confirm the fracture is in an
acceptable position
• TYPES OF CASTS- POP (less expensive, mouldable) and FIBREGLASS- lighter, more durable, more water resistant,

more easily penetrated by xrays , available in a variety of colors and patterns

• Stable fractures are generally reevaluated within one to two weeks following cast application to assess cast fit and

condition, and to perform radiography to monitor healing and fracture alignment.

• Hand and forearm fractures, however, are often reevaluated within the 1st week
 AREA OF INJURY TYPE OF SLAB/SPLINT TYPE OF CAST

Hand/finger Ulnar gutter, radial gutter, thumb Ulnar gutter, radial gutter, thumb
spica, finger spica

Forearm/wrist Volar/dorsal forearm, single sugar- Short arm, long arm

tong

Elbow/forearm Long arm posterior, double sugar- Long arm

tong

Knee Posterior knee, off-the-shelf Long leg

immobilizer

Tibia/fibula Posterior ankle (mid-shaft and Long leg (proximal fracture), short
distal fractures), bulky Jones leg (mid-shaft and distal)
Posterior ankle (“post-mold”),
Ankle stirrup, bulky Jones, high-top Short leg
walking boot
Posterior ankle with or without toe Short leg, short leg with toe box for
Foot box, hard-soled shoe, high-top phalanx fracture
walking boot
FUNCTIONAL BRACING

• commonly used in fracture-dislocations

• Segments of a cast are applied only over the shafts of the bones, leaving the joints free; the cast segments are
connected by metal or plastic hinges that allow movement of the joint in one plane.
• Widely used for fractures of the femur or tibia (applied only when the fracture is beginning to unite, i.e. after 3–
6 weeks of traction or conventional plaster)
 TREATMENT OF OPEN FRACTURES

• Wound inspected- gross contamination is removed, photographed- covered with a saline-soaked dressing under an

impervious seal to prevent desiccation.

• Antibiotics prophylaxis

• Tetanus prophylaxis

• The limb is then splinted until surgery.

• NV status checked repeatedly, particularly after any reduction manoeuvres

• CLASSIFICATION OF INJURY- Gustilo Anderson classification

DISADVANTAGES OF GUSTILO ANDERSON CLASSIFICATION

• Definition has undergone many modifications and does not have uniformity in application.
• Includes wide spectrum of injuries in Type IIIB injuries.
• Mainly depends on size of the skin wound.
• Does not evaluate the severity of injury to skin, bone and musculotendinous units separately.
• Does not address the question of salvage.
• Poor interobserver reliability.
ADVANTAGES OF GANGA SCORING

• Specifically designed for Type Illb injuries.

• Assesses severity of injury to skin, muscle, bone separately.
• Total score predicts amputation.
• Individual score provides guidelines for reconstruction.
• Scoring includes comorbidities which influences outcome.
• Better intra- and interobserver agreement compared to Gustilo classification.
o PRINCIPLES OF MANAGEMENT OF OPEN FRACTURES

 Antibiotic prophylaxis
 urgent wound and fracture debridement- wound excision, extension, delivery of fracture,
removal of devitalized tissue, wound cleansing, nerves and tendons
 early definitive wound cover
 stabilization of the fracture
 PRINCIPLES OF DEBRIDEMENT

• Debridement Principles - Experienced team and as early as possible; Ortho+plastic

approach

• Skin and Fascia- Wounds must be longitudinally extended to provide adequate

visualization, Margins trimmed to bleeding dermis (clean wound edge),Gentle handling

and prevention of degloving are essential, All avascular fascia must be excised

• Muscles- All evaluated for viability (“4 C” Color, Consistency, Contractility, Capacity to

bleed) and debrided.

• Bone- ends and medullary cavity carefully examined for foreign material, All fragments

without soft tissue attachment must be excised

• Lavage- adequate quantity of fluid with low-pressure pulsatile lavage

• Completion- Assess loss of tissues and document , Decide on method and timing of

wound closure or coverage and bone stabilization, Document sequence of reconstruction,

In very severe tissue loss VAC may be used

 STABILIZATION OF THE FRACTURE

• The method of fixation depends on the degree of contamination, time from injury to operation and amount of soft-

tissue damage

• If wound cover is delayed, external fixation can be used as a temporary measure

• The external fixator may be exchanged for internal fixation at the time of definitive wound cover as long as:
(1) the delay to wound cover is less than 7 days
(2) wound contamination is not visible
(3) internal fixation can control the fracture as well as the external fixator
 DEFINITIVE CARE

• DAMAGE CONTROL ORTHOPEDICS/SURGERY (DCO)

• EARLY TOTAL CARE (ETC)

• EARLY APPROPRIATE CARE

 DAMAGE CONTROL ORTHOPEDICS

 Approach to treat all fractures by definitive fixation in one trip to the operating room.

 Considered in patients who remain hemodynamically unstable or those with

• Hypothermia
• Abnormal base deficit
• Increased lactate
• Blood-clotting abnormalities

 Avoids provoking SIRS, fulfills sufficient stabilization to prevent further soft tissue damage, allows

mobilization.
4 phases-

1. Acute phase- lifesaving procedures

2. Second phase- control hemorrhage, temporary stabilisation, management of soft tissue injuries
(ensure minimal surgical insult)
3. Phase 3- monitoring period in ICU/HDU
4. Phase of definitive fixation

Follow DCO if- GCS less than 8, massive intracranial bleed, severe thoracic trauma, blood dyscrasias,
hypothermia (<32 C), hemodynamically unstable with uncompensated cardiac function.
• Very high levels of IL-6 is an early indicator of development of organ failure
• Window of opportunity- for definitive fixation- 5th to 10th day
 EARLY TOTAL CARE

• Involves definitive surgical stabilization of all long-bone fractures during the early phase of treatment,

usually within the first 24 hours.

• This may reduce pulmonary complications and allow earlier rehabilitation of the patient.

• Suitable for patients with multiple fractures who have been fully resuscitated and are hemodynamically

stable with normal blood gases, clotting, and temperature.

• Definitive fracture fixation should NOT take place if the lactate is greater than 3.0 mmol/L.

• Resuscitation should continue and a damage control strategy followed if the patient fails to improve.

• Close monitoring with the intensive care and anesthetic teams

 EARLY APPROPRIATE CARE

• Surgery is delayed for up to 36 hours while the patient is fully resuscitated so that all of their key physiological

parameters return to normal.

• During this time, long-bone fractures are splinted or put into skeletal traction before definitive skeletal fixation of

all unstable pelvic and spinal fractures, together with all long bone fractures.

• If the soft tissues are suitable and the surgical team is available, fixation of periarticular fractures may also be

considered within this time frame as it allows more rapid mobilization of the patient.
 INTERNAL FIXATION

• holds a fracture securely -movement can begin immediately- chances of stiffness and oedema is abolished

• Greatest danger- infection- risk depends upon PATIENT (devitalized tissues, a dirty wound and an unfit

patient) SURGEON (thorough training, a high degree of surgical dexterity and adequate assistance) AND

FACILITY (a guaranteed aseptic routine, a full range of implants and staff familiar with their use)

• Types- plates and screws( compression, buttressing, bridging, tension band, neutralization) intramedullary

nails, interfragmentary lag screws

• Complications- infection, non union, malunion, refracture, implant failure

 INDICATIONS OF INTERNAL FIXATION

• fractures that cannot be reduced except by operation

• fractures that are inherently unstable and prone to redisplace after reduction (e.g. midshaft fractures of the
forearm and some displaced ankle fractures) plus those fractures liable to be pulled apart by muscle action
(e.g. transverse fracture of the patella or olecranon)
• pathological fractures in which bone disease may inhibit healing
• multiple fractures where early fixation (by either internal or external fixation) reduces the risk of general
complications and late multisystem organ failure
• fractures in patients who present nursing difficulties (e.g. paraplegics, those with multiple injuries and the very
elderly).
 EXTERNAL FIXATION

• fractures with severe soft-tissue damage/contaminated,

• where internal fixation is risky and repeated access is needed for wound inspection, dressing or plastic surgery

• fractures around joints where soft tissues are too swollen– a spanning external fixator provides stability until soft-

tissue conditions improve

• patients with severe multiple injuries (bilateral femoral fractures, pelvic fractures with severe bleeding, and those with

limb and associated chest or head injuries)

• Nonunion- which can be excised and compressed; sometimes this is combined with bone lengthening to replace the

excised segment

• Complications- over distraction, damage to soft tissue, pin track infection, neurovascular damage, scar
 EXTERNAL FIXATION

ADVANTAGES

• Less damage to the blood supply of the bone

• Minimal interference with soft-tissue cover

• Rapid application in an emergency situation

• Stabilization of open and contaminated fractures

• Adjustment of fracture reduction and stability without surgery

• Minimal foreign body in the presence of infection

• Less experience and surgical skill required than for standard open reduction and internal fixation (ORIF)

• Bone transport and deformity correction possible

 INDICATIONS OF EXTERNAL FIXATION

• Temporary or definitive skeletal stabilization of open fractures, in particular those with severe soft-tissue injury

• for temporary bridging in severe polytrauma and severe closed soft-tissue contusions or degloving- applied

outside the zone of injury and potential surgery

• In simple articular fracture patterns, by a combination of interfragmentary lag screw fixation with an external

fixator

• manage major soft tissue and bone loss by primary shortening of the limb followed by secondary distraction

osteogenesis to restore limb length

• perform indirect reduction

THANK YOU