The principles of acute fracture management involve stabilizing the patient who may have other injuries more life-threatening, checking the neurovascular status of the patient, performing a reduction or attempting to correct the anatomic alignment, stabilizing the reduction with a splint or cast, with operative fixation if necessary. Each type of dislocation and fracture is treated differently depending on the specific injury.
Care of the Trauma Patient
Most fractures are isolated injuries; however, in the case of 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.
Trauma X-rays 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.
Damage-Control Orthopedics
According to the "Handbook of Fractures," the term damage-control orthopedics refers to the use of temporary fracture management when the patient is too unstable to undergo a definitive repair. An external fixation apparatus is often applied to the area to keep the bones at length and to protect the joints. The plan is usually to remove the external fixator at a later date and perform a more definitive repair.
Open Fractures
The term open fracture refers to when a fracture opens the skin. This is an orthopedic emergency. Fracture sites and joints need to be thoroughly "washed-out" with copious amounts of fluids. Patient are given antibiotics and a tetanus vaccine. Antibiotics are given based on the size of the wound and how "dirty" the wound is. The fractures are then stabilized either with an external fixation device or with plates, screws, nails and/or pins.
Nonoperative
Fractures and dislocations can often lead to displacement of the joint and bone fragments that require anatomic correction. The principle of a closed reduction is to recreate anatomic alignment and preserve appropriate joint space. Reduction maneuvers are performed without sedation, with local anesthetic, or with full sedation. The reduction is then held typically by a sling for shoulder injuries; placement of a plaster or fiberglass splint or cast for other fractures. For femur and acetabulum/hip socket fractures, the leg is often placed into traction by applying a pulling force on a pin that is drilled through the leg either above or below the knee. Traction is a temporary treatment until definitive repair can be done. The reduction may prove to be all that is needed to treat the fracture or dislocation; however, surgery may be indicated if the anatomic alignment cannot be maintained. An orthopedic surgeon will review the X-rays taken after the reduction to make the determination if surgery is indicated.
Operative
Open reduction internal fixation (ORIF) refers to any surgical procedure that involves a surgical incision and then placement of a fixation device. Types of fixation devices include screws, pins, plates and nails. Typical sites of nailing include the femur and tibia. Plates can be placed on nearly any fracture throughout the body. Screws and pins can also be used to help stabilize most fractures.
The external fixator involves placing pins through the skin above and below the fracture and then making a device with bars and tubes to stabilize the fracture. Common sites for external fixation use are ankle and wrist fractures. The external fixation device is often placed in conjunction with an open reduction internal fixation procedure if the fracture is very unstable.
References
- "AAOS Comprehensive Orthopaedic Review"; Dr Jay Lieberman (editor); 2008.
- "Handbook of Fractures (3rd ed)"; Dr. Kenneth Koval and Dr. Joseph Zuckerman (eds); 2006.
- "Handbook of Fractures (3rd ed)"; Dr. John Elstom et al; 2006.
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