Treatment of fractures

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Treatment of fractures

Aim of fracture management is to achieve healing of fragments in anatomic alignment.
For appropriate healing to take place the fractured bone ends need to be in close apposition; the site needs to be immobilised; and the patients need to have an adequate healing capacity.

Fractures immobilised:
• reduce discomfort
• prevent motion of fragments so healing is not interfered with

Closed reduction:
Manual alignment of fracture (under local or general anaesthetic)  immobilised in cast.

Closed reduction not indicated when:
• no displacement
• no reduction is possible (eg crush injury)
• open fracture
• not possible to use some form of external fixation after reduction

Advantages – avoidance of surgery; shorter hospital stay

Open reduction:
Surgical repair of fracture for alignment and fixation.

Use open reduction when:
• fracture is displaced and cannot be reduced by closed reduction
• articular surface involvement
• if avulsion forces caused the fracture
• need internal fixation due to multiple fractures

Advantages – more precise reduction of fracture; earlier mobilisation of joints;
Disadvantages – increase risk of infection; longer hospital stay; need for subsequent removal of implanted device

Eight principle of treatment of open fractures :
1) All open fractures treated as an emergency
2) Evaluation of patient for other life-threatening injuries
3) Appropriate and adequate antibiotic therapy
4) Adequate debridement and irrigation
5) Stabilisation of the open fracture
6) Early cancellous bone grafting
7) Appropriate wound healing
8) Rehabilitation

Fixation of fractures:
Splintage techniques:
1) Kirschner wires
2) Steinmann pins
3) Biodegradable rods
4) Surgical stainless steel wire
5) Staple fixation
Rigid Internal fixation:
1) Cortical screws
2) Cancellous screws
3) Plates a) Neutralisation plate (isolates fracture site from external forces; no compression forces applied)
b) Compression plate (applies compression force across simple fractures; risk of shortening if used across comminuted fracture)
c) Buttress plate (acts as a buttress – prevents movement and shortening)
4) Tension band
External fixation:
1) Frame

Electrical Stimulation of Bone:
Bone formation has been shown to occur with a current of 5-20 microamps

Based on theory that bone has an electrical negative charge over areas that are actively growing and repairing, so it is assumed that a negative charge can stimulate bone growth.

Types of stimulators:
Invasive:
• cathode is placed in fracture site and anode placed on skin
Semi-invasive:
• percutaneous insertion of cathode
Non-invasive:
• external device that provides a pulsating electromagnetic field

Contraindications:
Pseudoarthrosis
Large gap between fragments

Bone Grafts

Bone grafts are used to stimulate osteogenesis, assist in immobilisation and replace lost bone.

Types of grafts:
• autografts – from self
• allograft – dead bone from same species; usually freeze dried
• xenograft – bone from different species
• synthetic grafts -

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