Gregory R. Waryasz, MD Ashley Davidoff MD Copyright 2011
Introduction
Principles
Reduction
Immobilisation
Caring foirthe Trauma Patient
The principles of trauma and acute fracture management involve stabilizing the patient who may have other injuries more life-threatening. It is important to care for the patient in the order of the injuries that can cause death. Airway and breathing are the most vital parts of caring for any trauma patient followed by circulation. Fractures can cause significant bleeding especially if pelvic or femoral, however without a patent airway or ventilation, a patient will die prior to exsanguination from a fracture.
Most fractures are isolated injuries, however in the case of a polytrauma or multiple injuries due to trauma, it is important to stabilize the patient prior to managing the fracture unless the fracture itself is making the situation life-threatening. The acronym ABCDE is used in trauma care. “A” stands for airway, “B” for breathing, “C” for cardiovascular/circulation, “D” for disability, and “E” for exposure.
Airway management involves ensuring that the patient can either protect their airway or has an open airway to allow for breathing. Patients may require intubation or placement of a breathing tube. Patients can also have an object in the airway that may need to be removed to allow for patency of the airway to be achieved.
Breathing management involves checking to see if the patient is breathing on his/her own. If the patient is not breathing adequately, the patient can be intubated and placed on mechanical ventilation, a breathing machine to assist the patient with breathing.
Circulation is assessed by feeling the peripheral pulses. The body has many sites where the arterial pulsations can be felt including the wrist, foot, and groin. Blood pressure is measured using a blood pressure cuff. Overall appearance of the patient in combination with vital signs can help a physician assess if the patient is in a state of shock. Trauma patients can develop hypovolemic shock or shock due to blood loss from internal or external bleeding. Femur fractures are notorious for large volumes of blood loss. Controlling bleeding can involve stabilizing the pelvis or a long-bone fracture.
Disability refers to evaluation of the neurologic system including level of consciousness and an extremity neurologic exam.
Exposure involves a full visual inspection of the patient to assess for further injuries. Patient are usually stripped down to help with this assessment.
Trauma radiographs can then be taken and a further examination can be done to focus on individual fractures. With each fracture, the clinician will assess the peripheral pulses and neurologic function and sensation. If there is a known loss of pulse or neurologic deficit, the fracture must be treated more acutely.
Non-Operative Treatments
Casting
Casting is a technique to help immobilize a fracture so that the fracture fragments do not shift position. Casting can be done for a wide variety of fractures on the upper or lower extremity. Physicians can perform reduction maneuvers to help realign the fracture fragments in a better position for healing.
Common casting materials include fiberglass and plaster. Initially a stockinette is placed on the skin over the proximal and distal areas where the cast will be placed. Next cotton webril is wrapped circumferentially around the extremity with care to pad all bony prominences. Layers of either fiberglass or plaster are wrapped circumferentially around the extremity to provide a semi-rigid form of immobilization. As the fiberglass or plaster hardens, the clinician can help to apply a mold to hold the fracture reduction.
Common types of casts include short leg, long leg, spica, short arm, and long arm. The short leg cast includes the foot up to the base of the knee. The long leg cast includes the foot up to the thigh. A spica cast contains the feet through the lower abdomen to help immobilize the hips and rest of the lower extremity. A short arm cast goes from the proximal palmar crease to just distal to the elbow. A long arm case includes the hand and stops at the upper arm.
Casting can be a definitive treatment or a temporary treatment until further operative fixation can be performed. Due to post-fracture swelling, some casts are cut to allow for expansion, this can be either a univalve or a bivalve cast. Casts can also be applied post-surgery as well for fixation.
Splinting
Splinting is a technique that can be used in the setting of a recent fracture or as a method of reinforcing post-operative fixation. The splint is ideal for fractures associated with swelling as it is more open to expansion of an extremity than a cast. Splinting can be done in conjunction with a reduction maneuver to help realign the fracture fragments in a better position for healing.
Common splinting materials include plaster, fiberglass, and prefabricated splinting materials such as Orthoglass. Cotton webril is used to pad the splint either by circumferentially wrapping the cotton around the extremity or by placing strips over the splint. Care is taken to pad the bony prominences. The splint is then applied to the affected extremity. An ACE wrap is then wrapped over the splint to help hold its position. A clinician then applies a mold to the splint to hold the fracture fragments in a better position as the splint hardens.
Common types of splints include a “bulky jones”, sugartong, coaptation, ulnar gutter, volar/dorsal hand splint, thumb spica, posterior slab (ankle) with or without a U-shaped splint, and a posterior slab (thigh). The “bulky jones” splint is a lower extremity splint consisting of a posterior slab applied to the lower leg and a U-shaped slab that wraps from the lateral to the medial side of the ankle and up the leg. The “bulky jones” splint uses abundant cotton and padding to help with swelling. A sugartong splint is an upper extremity splint that involves a single splint that wraps volar and dorsal around the elbow and includes the hand. The sugartong splint is U-shaped. A coaptation splint is used for humerus fractures and is a U-shaped splint that wraps around the elbow and up the upper arm to the shoulder joint. The ulnar gutter splint involves a splint that wraps around the ulnar surface of the forearm leaving the radial surface free. The volar/dorsal hand splint is two splint slabs, one is on the volar forearm and hand, while the other is on the dorsal forearm and hand. A thumb spica splint helps to immobilize the thumb and is located on the radial forearm and hand. A posterior slab is a lower extremity splint applied to the posterior leg, it can include the ankle and/or thigh depending on the level of immobilization necessary. The posterior slab can be combined with a U-shaped splint to better immobilize the extremity if necessary. Finger and toe splints are often made of metal with padding and can be taped on to support the broken digits.
Splints are usually not the definitive treatment, but rather a temporary form of immobilization used preoperatively, postoperatively, or until swelling subsides and a cast can be applied. Splints can be removed and placed back on which is can be helpful for patients to ice a fracture site.
Walking Boot
Minor fractures of the ankle foot and toes can often be treated by placement of the injured extremity in a walking boot. This boot covers the foot and extends to just below the knee. It can allow for weight bearing early on in the fracture healing.
Sling
A sling is a commonly used to help with providing support and comfort for certain fractures. It can be used in conjunction with a cast or splint. For proximal humerus fractures, scapula, and clavicle fractures, a sling can be the definitive treatment. The shoulder sling has a pouch where the lower arm and elbow rest with a strap that wraps around the patients contralateral shoulder. The elbow is typically held in around 90 degrees of flexion. A swath can be used to help keep the arm close to the body.
Operative Treatments
External Fixation
External fixation is an operative method of fracture immobilization that involves the placement of percutaneous pins into bone on both sides of the fracture. Clamps are placed on the pins and metal bars are placed in the clamps to help keep the extremity at the appropriate length. The metal construct is outside of the body. Reduction maneuvers are done to help achieve improved alignment. External fixation is used for temporary or definitive management of fractures. It can be used in combination with an open reduction and internal fixation surgery or can be removed after the open reduction internal fixation surgery. External fixation can be used for open fractures, severely comminuted fractures, and for patients who cannot undergo an open reduction internal fixation surgery. A pelvic external fixation device is often performed to help control intra-pelvic bleeding in a polytrauma patient who is unstable. Some patients will have an external fixation device placed in the emergency department and will have it revised in an operating room at a later date.
Closed Reduction Percutaneous Pinning
Closed reduction percutaneous pinning is a procedure that can be used on a wide variety of fractures that involves placement of pins through soft tissue and into bone to help immobilize a fracture site. Kirschner or K-wires are drilled through the bone after a reduction maneuver is performed or fracture clamps are applied to hold the bones in alignment. Common fractures treated with closed reduction percutaneous pinning include pediatric supracondylar fractures, finger fractures, metacarpal fractures, and toe fractures. Foot and hand/wrist dislocations can be treated with percutaneous pinning as well.
Poor Anatomic Alignment |
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The transverse fractures of the shafts of both the radius and ulna are easily appreciated caused by a single force across the forearm arm resulting in simple transverse fractures of both. The bony components of the fractures are poorly aligned and if left will result in poor healing. Alignemnet if not accomplished or accomplishable by closed method will require ORIF – open reduction internal fixation with hardware. Courtesy Ashley Davidoff MD 72824.800 |
Treated by Closed Reduction |
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The transverse fractures of the shafts of both the radius and ulna are easily appreciated caused by a single force across the forearm arm resulting in simple transverse fractures of both. The forearm is now placed in a cast with significant improvement of the alignment of the radius and moderate improvement of alignment of the ulna. Courtesy Ashley Davidoff MD 72826.800 |
Open-Reduction Internal Fixation
Open reduction internal fixation is the term for operative repair of a fracture with placement of hardware under the skin. Orthopaedic implants are typically made of titanium or stainless steel. Common types of implants include screws, plates, cerclage wires, tension bands, dynamic compression screw, and intramedullary rods/nails. Screws are used to provide compression across a fracture and to secure a plate to a fractured bone. There are two generic types of screws; cortical and cancellous. Cortical screws have a shallow thread and a finer tpich that increases contact area with the cortical part of the bone. Cancellous screws have deep threads and a course pitch that help to maximize function in the soft cancellous bone. Plates are used to secure a fractured bone. Plates are secured with screws. There are a few types of plates; compression plating, neutralization plating, buttress plating, buttress plating, antiglide plating, bridge plating, percutaneous plating, locking plates, and less invasive stabilization system (LISS). Each type of plate has specific clinical indications for surgical fixation. Cerclage wires can be used to hold tension on a plate or bone strut against a fractures bone. Tension banding is a technique that helps to compress fracture fragments at the far cortex. Tension banding is typically done for olecranon and patellar fractures. Avulsion injuries are treated well by tension banding techniques. A dynamic compression screw is commonly used for intertrochanteric femur fractures. The dynamic compression screw helps to shorten the fracture by a sliding mechanism for controlled shortening that protects the femora head. Intramedullary nailing is used for long bone fractures of the femur, tibia, and sometimes humerus. To place an intramedullary nail, the canal can be reamed to allow for the smooth placement of the hardware into the center of the bone. The hardware can be secured with screws that go through the bone and the hardware exiting in the opposite cortex. Open reduction internal fixation of fractures can combine many different types of operative managements to help stabilize the fracture.
Arthroplasty or Hemiarthroplasty
Certain fractures based on location or level of comminution will not respond to open reduction internal fixation or external fixation procedures. The treatment for these fractures can be with arthroplasty or hemiarthroplasty to help rebuild the joint. An arthroplasty is a total joint replacement, while a hemiarthroplasty is replacing one-half of a joint articulating surface. Common arthroplasty procedures are for the elbow, shoulder, knee, hip, and ankle. Common hemiarthroplasty sites are for the humeral head and femoral head. Fractures of the radial head are often treated with a radial head replacement procedure.
Skeletal Traction
Long bone fractures are often initially treated with skeletal traction to help to stabilize the fracture site and help with reduction. Some patients are treated definitively with skeletal traction if they are not surgical candidates for other reasons. Long bone, pelvic, and acetabulum fractures are often treated initially with skeletal traction. The process of skeletal traction involves percutaneously placing a pin in the distal femur, tibia, or calcaneus. A counterweight is used to apply an axial force on the fracture to help bring the extremity back to length.
Pain Control
NSAIDs
Nonsteroidal anti-inflammatories (NSAIDs) are medications that provide pain relief and help to reduce inflammation. Common types of NSAIDs are ibuprofen and naproxen.
Acetaminophen
Acetaminophen (Tylenol) is a medication that provides mild pain relief.
Opioids
Opioids are controlled substances that function as pain relievers. They are particularly helpful in the immediate post-fracture or post-operative stages of management. Common opioids used include morphine, fentanyl, hydromorphone (Dilaudid), and hydrocodone. Vicodin and Percocet are combination medications of acetaminophen with an opioid that are taken orally. Opioids are commonly taken intravenously, orally, or subcutaneously for fractures.
Special Considerations
Open Fractures
An “open fracture” is a term that describes a fracture where there is a break in the skin and soft tissue that communicates with the fracture site. A compound fracture is an older term for an open fracture. Open fractures need to be irrigated copiously to clean the area. The Gustilo and Anderson Classification System is used to describe open fractures. Grade I open fractures are less than 1cm of skin opening. Grade II open fractures are more than 1 cm of skin opening with extensive soft tissue damage. Grade III open fractures occur when there is extensive soft tissue damange. Grade I and II open fractures are treated with 1g of cefazolin every 8 hours. Grade III open fractures are treated with 1 g of cefazolin every 8 hours and an aminoglycoside antibiotic 3-5mg/kg/day. If there is organic contamination of any open fracture, penicillin 2 million units is given every 4 hours or metronidazole 500mg every 6 hours. Tetanus prophylaxis should also be given.
References
Elstrom J, Virkus W, Pankovich (eds), Handbook of Fractures (3rd edition), McGraw Hill, New York, NY, 2006.
Koval K, Zuckerman J (eds), Handbook of Fractures (3rd edition), Lippincott Williams & Wilkins, Philadelphia, PA, 2006.
Lieberman J (ed), AAOS Comprehensive Orthopaedic Review, American Academy of Orthopaedic Surgeons, 2008.
Moore K, Dalley A (eds), Clinically Oriented Anatomy (5th edition), Lippincott Williams & Wilkins, Philadelphia, PA, 2006.