Ao Principles Of Fracture Management Pdf Free Download ((BETTER))

processing.... Drugs & Diseases > Orthopedic Surgery General Principles of Fracture Care Treatment & Management Updated: Mar 31, 2022 Author: Richard Buckley, MD, FRCSC; Chief Editor: Murali Poduval, MBBS, MS, DNB more... Share Print Feedback Close Facebook Twitter LinkedIn WhatsApp Email webmd.ads2.defineAd({id: 'ads-pos-421-sfp',pos: 421}); Sections General Principles of Fracture Care Sections General Principles of Fracture Care Overview Practice Essentials Pathophysiology Etiology Epidemiology Show All Presentation History and Physical Examination Description and Classification Complications Show All Workup Laboratory Studies Imaging Studies Other Tests Show All Treatment Approach Considerations Elements of Initial Fracture Management Nonoperative Therapy Surgical Therapy Postoperative Care Complications Long-Term Monitoring Show All Media Gallery Tables References Treatment Approach Considerations Fracture management can be divided into nonoperative and operative techniques. The nonoperative approach consists of a closed reduction if required, followed by a period of immobilization with casting or splinting. Closed reduction is needed if the fracture is significantly displaced or angulated. [39] Pediatric fractures are generally much more tolerant of nonoperative management, owing to their significant remodeling potential. [40]

Nondisplaced fractures all require a period of healing that may or may not involve cast care. In this time of aggressive operative treatment, only simple nondisplaced fractures of long bones or joints may be treated with nonoperative cast care; the rest are treated with emergency operative care so as to allow early motion and thereby prevent stiffness of adjacent joints.

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The initial management of fractures consists of realignment of the broken limb segment (if grossly deformed) and then immobilizing the fractured extremity in a splint. The distal neurologic and vascular status must be clinically assessed and documented before and after realignment and splinting. If a patient sustains an open fracture, achieving hemostasis as rapidly as possible at the injury site is essential; this can be achieved by placing a sterile pressure dressing over the injury site (see Open Fractures).

Once the initial assessment, evaluation, and management of any life-threatening injury are completed, the open fracture is treated. Hemostasis should be obtained if there is significant ongoing bleeding, though bone bleeding is best reduced by anatomic reduction. Gross contaminants can be removed if possible and the soft-tissue wound can be covered by a sterile dressing moistened with normal saline. Harsher adjuncts, such as iodine solutions, are not recommended, because of their cytotoxic effects. [43] Tetanus immunization should be provided if the patient does not have current immunity.

For type I and type II fracture injuries, a first-generation cephalosporin (eg, cefazolin) is adequate. If the wound is severely contaminated (type III), an aminoglycoside (eg, gentamicin, tobramycin) is commonly added to complement treatment. If the injury is a "barnyard injury" (contaminated with soil) or water-type injury, penicillin may also be added to provide prophylaxis against Clostridium perfringens and other anaerobes.

Rodriguez et al reported on the use of an evidence-based antibiotic protocol based on open fracture grade, in which patients with grade I or II fractures received cefazolin (clindamycin in the case of allergy) and those with grade III fractures received ceftriaxone (clindamycin and aztreonam in the case of allergy) for 48 hours; aminoglycosides, vancomycin, and penicillin were excluded from the protocol. [44] Implementation of this protocol for open fracture antibiotic prophylaxis led to significantly reduced use of aminoglycoside and glycopeptide antibiotics without increasing rates of in skin and soft-tissue infection.

The traditional teaching of open fracture management was that urgent irrigation and debridement (I&D) of the wound in the operating room (OR) is mandatory within 6 hours and that open fractures are considered orthopedic emergencies. More recent data, such as the findings from the Lower Extremity Assessment Program (LEAP), suggested that surgical I&D within 24 hours of injury is sufficient. [43] For type II and type III injuries, serial I&Ds are recommended every 24-48 hours after the initial debridement until a clean surgical wound is ensured and no necrotic tissue persists.

There is some controversy with regard to the most appropriate type of irrigation fluid, the optimal volume, and the preferred degree of pressure. Antisepsis must be balanced against the cytotoxic effect on the native tissues. Bhandari et al advocated the use of simple normal saline for irrigation via a low-pressure delivery system. [43] A widely accepted approach is to use a minimum of 3 L of irrigation for a type I fracture, 6 L for a type II fracture, and 9 L for a type III fracture.

The wound is closed when it is clean, ideally within 3-7 days of the initial injury; the risk of infection and flap failure rise precipitously when closure of type III fractures occurs more than 7 days after injury. [43] Plastic surgery colleagues may need to be involved in the wound closure.

Management of the open fracture depends on the site of injury and type of open fracture. The wound is subsequently stabilized either temporarily or definitively. If soft-tissue coverage over the injury is inadequate between debridements, wet-to-dry dressings or negative-pressure wound therapy (eg, vacuum-assisted closure [VAC] dressings) may be used. If the fracture reduction cannot be maintained between debridements, an external fixator may be used, with the pin sites well outside the zone of injury. [5]

Early fracture management is generally aimed at controlling hemorrhage, providing pain relief, preventing ischemia-reperfusion injury, and removing potential sources of contamination (foreign body and nonviable tissues). Once these tasks are accomplished, the fracture should be reduced and the reduction should be maintained, which will optimize the conditions for fracture union and minimize potential complications.

The ultimate goal of fracture management is to ensure that the involved limb segment, when healed, has returned to its maximal possible function. This is accomplished by obtaining and subsequently maintaining a reduction of the fracture with an immobilization technique that allows the fracture to heal and, at the same time, provides the patient with functional aftercare. Either nonoperative or surgical means may be employed.

Closed reduction should be performed initially for any fracture that is displaced, shortened, or angulated. This is achieved by applying traction to the long axis of the injured limb, reversing the mechanism of injury/fracture, and finally immobilizing the limb through casting or splinting. Splints and casts can be made from fiberglass or plaster of Paris. Barriers to accomplishing reduction include soft-tissue interposition at the fracture site and hematoma formation that create tension in the soft tissues.

For hundreds of years, traction has been used for the management of fractures and dislocations that cannot be treated by means of casting. With the advancement of orthopedic implant technology and operative techniques, traction is rarely used for definitive fracture/dislocation management. Two types of traction exist: skin traction and skeletal traction.

In skin traction, traction tapes are attached to the skin of the limb segment that is below the fracture or a foam boot is securely fitted to the patient's foot. In the application of skin traction, or Buck traction, usually 10% of the patient's body weight (up to a maximum of 10 lb [~4.5 kg]) is recommended. [40] At weights greater than 10 lb, superficial skin layers are disrupted and irritated. Because most of the forces created by skin traction are lost and dissipated in the soft-tissue structures, skin traction is rarely used as definitive therapy in adults; rather, it is commonly used as a temporary measure until definitive therapy is achieved.

In skeletal traction, a pin (eg, a Steinmann pin) is placed through a bone distal to the fracture. Weights are applied to this pin, and the patient is placed in an apparatus to facilitate traction and nursing care. Skeletal traction is most commonly used in femur fractures: A pin is placed in the distal femur (see the image below) or proximal tibia 1-2 cm posterior to the tibial tuberosity. Once the pin is placed, a Thomas splint is used to achieve balanced suspension.

Prophylactic antibiotics (cefazolin, 1-2 g) should be administered prior to incision. If the patient is allergic to penicillin, clindamycin can be administered. Patients with open fractures should be given appropriate antibiotic prophylaxis (see Elements of Initial Fracture Management). There is no evidence to support continuing prophylactic antibiotics beyond 24 hours postoperatively. [43]

Kirschner wires (K-wires) are commonly used for temporary and definitive treatment of fractures. However, K-wires resist only changes in alignment; they do not resist rotation, and they have poor resistance to torque and bending forces. K-wires are commonly used as adjunctive fixation for screws or plates and screws that involve fractures around joints.

When K-wires are used as the sole form of fixation, they are supplemented by casting or splinting. The wires can be placed percutaneously or through a miniopen mechanism. K-wire fixation has been used for small fragments in metaphyseal and epiphyseal regions, especially in fractures of the distal foot, wrist, and hand (eg, Colles fractures) and in displaced metacarpal and phalangeal fractures after closed reduction. [23] K-wires are also commonly used as adjunctive therapy for many fractures, including patellar fractures, proximal humerus fractures, olecranon fractures, and calcaneus fractures. ff782bc1db