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5 - Treatment of Fractures Notes

5 - Treatment of Fractures Notes - principles of treatment...

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*** principles of treatment - Treat the patient, not only the fracture o General resuscitation is the first consideration ABC - Treatment of the fracture o Manipulation Improve the position of the fragments o Splintage Hold the fragments together until they unite o Joint movement and function must be preserved o Exercise and early weight bearing Fracture healing is promoted by muscle activity and bone loading Main obj’s = REDUCE, HOLD, EXERCISE ***Fracture quartet: dual conflict o Encapsulates four important factors that influence the modern approach to fracture management - Hold vs. Move o How to hold a fracture adequately and yet use the limb sufficiently - Speed vs. Safety o surgeon seeks to resolve first conflict as rapidly as possible (eg with internal fixation), but without incurring unnecessary risks ***Closed Fractures Reduction - no undue delay in attending to the fracture o although general treatmtent and resuscitiaton must always take precedence o swelling of soft parts in first 12 hrs makes reduction increasingly difficult - reduction unnecessary when: o There is little or no displacement o Displacement does not matter Eg in some fractures of the clavicle o Reduction is unlikely to succeed Eg with compression fractures of the vertebra - Aim of reduction o adequate apposition o normal alignment of the bone fragments greater contact surface area between fragments more likely to heal gap delayed union or non-union fractures involving an articular surface should be reduced as near to perfection as possible: any irregulartiy will predispose to degenerative arthiritis - Methods of reduction o Manipulation o Mechanical traction o Open operation
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***Manipulation - Closed manipulation is suitable for 1. All minimally displaced fractures 2. Most fractures in children 3. Fractures that are likely to be stable after reduction - Unstable fractures are sometimes reduced ‘closed’ priort to mechanical fixation - Three fold maneuver: under anesthesia and muscle relaxation 1. The distal part of the limb is pulled in the line of the bone 2. The fragments are repositioned as they disengage a. By reversing the original direction of force if this can be deduced 3. Alignment is adjusted in each plane o Closed manipulation is Most effective when the periosteum and muscles on one side of the fracture remain intact; the soft T strap prevents over- reduction and stabilizes the fracture after it has been reduced ***Mechanical Traction - Some fractures ( eg of the femoral shaft ) are difficult to reduce by manipulation because of powerful muscle pull - They can often be reduced by sustained mechanical traction, which then serves also to hold the fracture until it starts to unite - In some cases, rapid mechanical traction is applied, under anaesthesia and assisted by image intensification, prior to internal fixation ***Open Operation Operative reduction under direct vision is indicated: 1. When closed reduction fails (either because of difficulty in controlling the fragments
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